Family Reaction to Death

Laura Havstad was interviewed by Katherine Kott about a recently published book chapter Dr. Havstad wrote on death and the family system. Here is an edited transcript of the interview.

Katherine Kott (KK): You contributed a chapter called Family Reaction to Death in Clinical Practice: An Approach Based on Bowen Theory to a recently published book Death and Chronic Illness in the Family: Bowen Systems Family Theory Perspectives. What prompted you to write the chapter you contributed? How did you get involved in this project?
Laura Havstad (LH): I had an interest in the role of the family system in resilience and how the family system creates different trajectories for each of its members in how well they adapt or they don't adapt following life events, especially with death and loss. The research findings on resilience of psychologist George Bonanno and his group resonated with Bowen theory in a way that I wanted to understand better. So Spring 2015 we (PBT) held a meeting, Adjusting to Death and Loss, with University of Nevada psychologist Dr. Anthony Papa who had been part of Dr. Bonanno's group at Columbia. Tony had research on the preservation of self and identity after loss—another idea resonant with Bowen theory. The video for that meeting on family and adjusting to loss with Dr. Papa and Dan Papero is available for downloading or streaming for people who are interested in learning more. So when Peter Titleman and Sydney Reed were looking for papers from the Bowen network on death and chronic illness in the family for an edited volume, I had an idea about the connection between the family emotional system, resilience and symptom development after loss that I wanted to test out by writing about it. And, I had a long term clinical example to do it with.
KK: So the conference here and the paper that you wrote were really pretty closely integrated?
LH: I was interested in trying to better define the connection between what the resilience research showed about the trajectories of well-being and dysfunction after loss and the hypothesis that the family emotional system is responsible for much of the variability. That idea was in mind with the meeting we did with Dr. Papa and Dr. Papero on adjustment to death following loss. It was at the spring 2016 meeting at the Bowen center on death and the family where Dr. Papa was also an invited speaker that I put together a presentation that outlined the chapter I wrote for this book.
KK: Any other ideas from the conference on Adjusting to Death and Loss that are reflected in the chapter you wrote?
LH: Yes. The observations that were coming out of the resilience research on how people do after loss had implications for the response in the helping professions. In many quarters it was presumed that most people were going to have difficulty adjusting that weren’t going to resolve without therapy. Research basically showed that most people will have reactions to loss, and may suffer disruptions in the early months following loss, and they usually recover their level of functioning. It's not that they don't continue to feel loss and to feel grief, but they're not in any clinical sense symptomatic or failing in life.
KK: They are not debilitated in some way.
LH: Yes. Exactly. Some people do seem to not recover but it is a much smaller percentage of people. Some people had a delayed reaction. But the research was saying that if mental health is assuming that people are going to not be able to recover without therapy, that's a mistake. People don't need therapy to recover. If people are being told that they need therapy or they won't recover, that adds to their difficulty recovering. Complications can come from that attitude.
KK: Ah, interesting.
LH: In the family, one of the relationship patterns that can lead to dysfunction is over-functioning and focus on what's wrong with the other. There is anxiety in the one who's doing the focusing, but it's projected. It's as if the problem is only in the other. That is a pattern that over the long run leads to increased chronic anxiety for the individual who's focused on if they go along with it and often even if they don’t. It’s a pattern that leads to symptoms.
KK: That's so interesting. I guess I hadn't fully understood. It makes sense to me now the way that you're saying it. That's the family piece and the awareness that family members need to have in terms of the emotional process in the family around a death or an illness.
LH: Yes. The same emotional process operates in society and in helping professions where there can be a focus on the weakness on the other that leads to more weakness in the other. This is a pattern in which the one focused on loses self to the other. So very interesting to me about Dr. Papa's research is the focus on preservation of the sense of self or identity following loss. Trouble in that area is a critical variable when there is difficulty recovering.
This might change the target of what you want to help people with. It’s a different orientation than focusing on grief and trying to get people to express grief. Instead, you might help them focus on something different.
KK: Right. So that actually leads to the third question that I had in mind to ask you, which would really be especially for people who are new to Bowen theory, thinking about ways that would be different as they work with the clients who might be coming to them because they think they're supposed to as they're dealing with the death of a family member. How would a Bowen theory approach be different from conventional approaches that would focus on feelings. Instead you're advising that perhaps they really want to look at places where the person has an interest in life, an engagement in life that they can reclaim or build on or something like that?
LH: Yes, right. Of course it depends who comes to you and the position they're in as to what you want to help them with. If it's someone coming to you in the family who's worried about somebody else's functioning in the family, you help them respect and not overreact to the fact that of course people are going to have some temporary difficulties and are going to be emotional following loss.
LH: Ultimately with each person, you help them recognize the family emotional system and its impact on self and others. Then you help them define themselves within that system, whether it's to make space for themselves or to quit taking the space of others, for instance to quit pressuring others. The clinical example in the paper illustrates this aspect. But often to begin with you want to support individual functioning and connections. Support their personal decision making. Encourage them to think for themselves and act with some confidence based on their own thinking about what's important to them in decision making about the funeral, about who they connect with and how, about what they're going to do. You support people in being connected in their own family rather than trying to put them into a therapeutic system, you try and support their functioning in their families and their own personal networks and take advantage of what's there. You can help them when challenges come out of the relationship system. People can mean to be helpful and be actually creating pressure and you can help them with that so that they don't have to throw out the baby with the bath water.
So those would be the things, as opposed to focusing on the expression of grief. You don't stop people from expressing grief. For the most part, people don't really need help in expressing grief when they are lost in it, they need help with a lot of rather significant adjustments they have to make.
KK: Exactly, yes. To a life that might be changed because the family system has changed.
LH: The family system has changed and people can get lost. They can lose self in these processes in the family system. It's a reconstitution of self or re-finding of self, or redefinition of self that helps people get outside the patterns that impair them.
KK: In your chapter, you have a case study. So there might be some aspects of that case study you'd like to mention, just to give examples of what you've outlined here.
LH: The case study is about a family where there was a prolonged reaction to loss in what Bowen called the shock wave that can follow death. Often anxiety in the family goes up after death, especially with an unexpected sudden death such as in this family that suffered the accidental death of a young adult child. Families might not connect the symptoms down the line with the death that initiates a shock wave. But when chronic anxiety goes up in families, the patterns for managing anxiety intensify and this is a big part of symptom development. Certain people in the family feel the brunt of that more. They begin to react to it more, the family ends up focusing on them more, either in a reciprocal process where they are one down or in the family projection process where the triangle comes in and it is a two or more against one.
The one on the receiving end of the anxiety develops symptoms. By the way, this is not intentional in the family, it's happening very automatically. Then the case example goes on to show how someone who decides to take leadership in the family and one of the better functioning family members decides to take on understanding the family system and then working on their part in it. That means working towards differentiation of self. Over time, that moderates the patterns. As the patterns moderate, this relieves pressure on the symptomatic one and the symptoms moderate as well. So it's a good example of a long-term process towards differentiation and the resolution of the chronic anxiety and symptoms that developed after the sudden death of a young person in a family.
Bowen, M. (1976) Family Reaction to Death. In M. Bowen (Ed.) Family Therapy in Clinical Practice. (pp. 321-335). NY, New York: Jason Aronson.
Bonanno, G. A. (2005). Resilience in the face of potential trauma. Current directions in psychological science, 14(3), 135-138.
Papa, A., Sewell, M. T., Garrison-Diehn, C., & Rummel, C. (2013). A randomized open trial assessing the feasibility of behavioral activation for pathological grief. Behavior Therapy, 44(4), 639-650.