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Abstract

In drawing together ideas from stress research, crisis studies and loss research a new and more satisfactory conceptual field has emerged—the field of Psycho-social Transitions.Such situations are seen as turning points for better or worse psycho-social adjustment. They often constitute natural experiments of great theoretical and practical importance.Grief is seen as a process of “realization” by means of which affectional bonds are severed and old models of the word and the self given up. It tends to be avoided and accounts for resistance to change and depressive reactions to change.
Words 9,807
Soc. Sci. & Med. 1971, Vol. 5, pp. 101-115. Pergamon Press. Printed in Great
Britain.
Chapter 13 PSYCHO-SOCIAL TRANSITIONS:
A FIELD FOR STUDY
"A
state without the means of some change is without the means of its conservation."
EDMUND WALLER, Reflections upon the Revolution in France.
During the 1960s I was exploring some of the wider implications of our theories of bereavement
by studying other types of loss such as loss of a limb and, with Roy Fitzgerald, loss of sight. From
the outset it was clear to me that, while attachment theory had much to contribute to our
understanding of the loss of persons, people were not attached to their limbs and eyesight in the
same way that they were to people, nor did they grieve in quite the same way when these faculties
were lost. A different theoretical model would be needed to explain these and other non-human
losses.
The starting point was to ask 'What is lost?' In the case of bereavement that was obvious, it is a
person to whom we are attached and, as we have seen, the biological roots of attachment
predispose us to cry and to search for them even when we know that the search is pointless. In
other losses searching can be a similarly meaningful response to the loss of an object or
possession but it makes less sense when evoked by loss of a limb, loss of vision, loss of a job
etcetera,.
It was the examination of these problems that caused me to re-examine our internal worlds in the
hope of explaining our reactions to these other losses. The term 'Psycho-social transitions' did
not catch on but my underlying idea of the Assumptive World did. It is a simple concept that has
profound implications. Since this paper was published the ideas it embodies have given rise to
several other significant publications the most notable being Janoff-Bulman's book (1992)
Shattered Assumptions: Towards a new Psychology of Trauma and Kauffman's multi-contributor
book (ed.) (2002) Loss of the Assumptive World: A theory of traumatic loss. (Brunner-Routledge,
NY and Lond.). For a recent update see Darcy Harris' 2013 paper 'New Understandings of
Death and Grief'. In the end the wheel was to come full circle for the theory that explained the
response to non-human losses turned out, in addition, to advance our understanding of losses of
humans and the whole concept shed light on the difference between the real world and our
assumptions about it.
References: Harris, D (2013) New Understandings of Death and Grief'.???
Janoff-Bulman, R (1992) Shattered Assumptions: Towards a new Psychology of Trauma. The
Free Press, NY.
Kauffman, G (2002) Loss of the Assumptive World: A theory of traumatic loss. Brunner-
Routledge, NY and Lond..
Abstract- In drawing together ideas from stress research, crisis studies and loss
research a new
and more satisfactory conceptual field has emerged - the field of
Psycho-social Transitions.
Such situations are seen as turning points for better or
worse psycho-social adjustment.
They often constitute natural experiments of great theoretical and practical
importance. Grief is seen as a process of "realization" by means of which affectional
bonds are severed and old models of the word and the self given up. It tends to be
avoided and accounts for resistance to change and depressive reactions to change.
THE RESEARCH field to be considered here represents a departure from the traditional
disease-
oriented field of psychiatry. Attempts to discover the aetiology of established
psychiatric syndromes
have rarely succeeded in demonstrating a one-to-one relationship
between a syndrome and any of
the many factors which have been postulated to account
for it. Most investigators have come to
accept that particular diseases are the consequence
of the complex interaction of many different
factors and that generalizations about any one
are not possible. Others, particularly psychoanalysts,
have continued to make generalizations about the constellations of aetiological factors which they
regard as important, but
have been unable to develop scientific means of testing the truth of
these generalizations.
Despite all disagreements there remain certain situations and events which most clinicians
continue to look for and to regard as at least partial causes of the mental disorders which
occasionally follow them; these include disasters, bereavements, childbirth, changes of
occupation, retirement, migration, major physical illness, and disablement. They have been
variously designated as "stresses" or "crises", but these terms are not altogether satis
f
actory. In
the first place, the terms have come to have so wide a meaning as to give no
clear indication
of their limits. In the second place there is, in their use, implication of outcome since a
stressor is defined in terms of its effects.
It
seems better not to prejudge the
question of
whether or not a particular event will prove "stressful".
In a statistical and predictive sense, an event X may be regarded as a possible or probable
source of stress if the proportions of the population having the sequence XY (where Y=
disequilibrium) are known. In a substantive, retrospective sense, it may have been
demonstrated that X was the source of stress, but in neither case does the concept carry us
beyond a description of an actual or potential occurrence.
The notion of crisis is bounded by similar difficulties, although its dramatic quality
encourages analysis. Thus, for example, we have Erikson's [1] distinction between
"developmental" and "accidental" crises. But the problem remains that an event which may be
a
crisis for one person can be a moment of unperplexing opportunity for another. Furthermore,
both terms have strongly negative connotations. This makes it difficult to consider a
positive
outcome to an apparently critical event. Crisis can lead to the stars as well as to the grave. If the
term is confined to a situation of "imbalance between the difficulty and the importance of the
problem and the resources immediately available to deal with it", the question has to be asked,
how do we know when there is imbalance? The answer lies in the quality of the outcome. Thus a
crisis occurs when there is imbalance and there is imbalance
when there is a crisis. In itself the
concept tells us nothing more than that there has been an
unfortunate congruence of forces. It is
essentially descriptive, retrospective and negative.
Independently of "stress research" an
increasing number of studies have been carried
out in recent years into the effects of major losses
in people's lives. Stemming from Freud's [2] attempts to link "mourning" and "melancholia"
these have led dynamically-oriented psychiatrists to study the effects of separating children from
their mothers and the effects of
bereavement in adult life and have caused them to develop
theories of "Object Relations"
which relate mental illness to the development of unsatisfactory
modes of coping with losses
throughout the course of the life span.
Whilst "stress research" has been developed as a field by experimental psychologists and
physiologists "loss research" has emerged from clinical psychoanalysis and been developed
by
social psychiatrists. Since most losses can be construed as stressful and many stresses
can be
construed as losses there must be a considerable overlap between these two fields and
there is a
need to try to link them together.
But what do we mean by a loss? Are there not many events which can be construed as
both
gains and losses ("You are not losing a daughter but gaining a son.")? Does the bride
who is left at
the church lose the husband whom she has never had? Writers on this subject
seem wary of
specifying just what they mean by a loss. Perhaps this stems from the difficulty
which we have in
defining the frame of reference.
As I see it losses and gains are two ways of classifying changes in state. In the former case
the end
state is assumed to be worse than the initial state whereas in the latter case the end
state is
assumed to be better. The designation of a change of state as a loss or a gain is,
therefore,
dependent on an evaluation of outcome and there will occasionally occur major
changes in state
where the pros and cons balance out so well that they cannot be seen as
either a gain or a loss.
Whenever a major change in state takes place the need arises for the individual to restructure his
ways of looking at the world and his plans for living in it. Whether we construe the
change as a
gain or a loss it is likely to require effort. Old patterns of thought and activity
must be given up
and fresh ones developed. It is not only losses which are commonly believed
to carry a risk of
maladjustment, gains too can be hazardous. Promotions, engagements, the
birth of a child, even
winning the football pools have been blamed for the failures in adjustment which occasionally
follow them. Whether the situation is seen as gain or loss one is
tempted to think that the crucial
factor may be the way in which the individual copes with the process of change.*
* Tyhurst [4] has used the term "Transition state" in writing of the reaction to change but I
prefer to regard
transition as a process rather than a state and to reserve the term "state" for
the relatively static situations
which precede and follow the transition.
B
ut what is it that changes? In the first place the change is likely to take place in that part
of the
world which impinges upon the self. This is what Kurt Lewin [3] has called "the Life
Space".
The life space consists of those parts of the environment with which the self interacts
and in
relation to which behaviour is organized; other persons, material possessions, the
familiar
world of home and place of work, and the individual's body and mind in so far as he
can view
these as separate from his self.
It
does not include those parts of the world, the
body and
the mind with which the self does not interact (and this, of course, is most of the
world,
much of the body and a large part of the mind).
Changes in the life space are important or unimportant depending upon their influence
upon the assumptions which we make about the world. For instance, sudden loss of vision
involves a change in the life space which is important or unimportant depending upon
whether the individual believes himself to have gone blind or to have voluntarily closed
his
eyes. Out of the "total set of assumptions which we build up on the basis of past experience in
carrying out our purposes" we create our own "Assumptive World".* A particular
constellation
*
This contraction of Cantril's [5] "Assumptive Form World" is an attempt to broaden
Cantril's concept to
include conceptual as well as perceptual elements.
of sensations is perceived as "a window" only because we have had meaningful experience with
windows in the past, the constellation has become a part of our assumptive
world enabling us
to "recognize" windows when we see them and make correct predictions
about their
characteristics and their utility.
The assumptive world is the only world we know and it includes everything we know or
think we know.
It
includes our interpretation of the past and our expectations of the future,
our plans and our prejudices. Any or all of these may need to change as a result of changes
in the life space.
The life space is constantly changing, novel stimuli, fresh combinations of events, unique
communications from others are received and assimilated. Some of these changes fulfill
expectations and require little or no change in the assumptive world, others necessitate a
major restructuring of that world, the abandonment of one set of assumptions and the
development of a fresh set to enable the individual to cope with the new, altered life space. If
the change takes place gradually and the individual has time to prepare, little by little, for
the
restructuring, the chances that this will follow a satisfactory course are greater than they
would
be if the change was sudden and unexpected. Thus the transitions of maturation
growing in
size, changing in appearance, becoming gradually older and more frail-are
barely recognized
as changes at all whereas the unexpected loss of a job or wife is more
likely to be
recognized as a major transition.
Let us look more closely at those major changes in life space which are lasting in their
effects, which take place over a relatively short period of time and which affect large areas of
the assumptive world. I shall call these "Psycho-social Transitions". An example will help to
illustrate some aspects of this approach. Loss of a job deprives a
man of a place of work, the
company of workmates and a source of income.
It
therefore
produces several changes in his
life space. What corresponding changes can be expected in
the assumptive world? Clearly
assumptions about the way in which each day must be spent
will change, assumptions about
the sources of money and security will change and the
individual's faith in his own capacity
to work effectively and to earn are also likely to change.
His view of the world as a safe, secure
place will change, his expectations of his future and his family will change and he is likely to
have to re-plan his mode of life, sell possessions and maybe even move to a place where his
prospects are better. Thus his altered
assumptive world will cause him to introduce further
changes in his life space, to set up a
cycle of internal and external changes aimed at
improving the "fit" between himself and his
environment. In order properly to understand the
effects of loss of a job it is necessary to
identify those areas of the life space and the
assumptive world which will or should change
as a consequence of the initial change in the
life space.
A man is tied to his assumptive world. By learning to recognize and act appropriately
within
his expectable environment a man makes his life space his own. Anything which I
can call
"mine" - "my" job, "my" home town, "my" left arm, "my" wife - become, to
some
extent, part of myself. To all of these things we are tied by bonds which (with
Harlow
[6]) I have termed "affectional bonds".
It
is the nature of an affectional bond that it
resists
severance and any change in life space is likely to require of us the severance of
affectional
bonds. Hence resistance to change is to be expected whenever the change requires
us to give
up a part of the life space to which we are accustomed.
The assumptive world not only contains a model of the world as it is (John Bowlby [7]
calls this "The World Model"), it also contains models of the world as it might be (these
models may represent probable situations, ideal situations or dreaded situations). [ I n l a t e r
p a pe r s ( Se e p .X X X ) I w a s t o c h a n g e m y m i n d . M o d e l s o f t h e w o r l d t h a t
m i g h t
b e ar e n o t a ss u mp t io n s a b o u t t h e w a y i t i s a n d a r e b et t er s e e n a s
b e lo n gi n g o u t s i d e t h e a s s um p t i v e w o r l d . O n t h e o t h e r h a n d c o n f i d e n t
a s su m pt io n s a b o u t t h e f u t ur e c er t a in l y b e l o n g i n t h e a s s u m p t i v e w o r l d
a s i n t he ex a m pl e t h a t f o l l o w s ] Models of
the world as it might be are used as a
rehearsal ground for actions appropriate to these
worlds. The bride-to-be rehearses in her
mind the world which she hopes to create, she
furnishes her home and peoples it with
children.
It
may be almost as hard for her to give up
models such as these as it is to give up
objects which actually exist. Hence the girl who has
planned for a marriage loses something
very important if she is jilted. The change which
she has to cope with is a change in her
own assumptive world.
The comparison which is made between ideal models of the world and models of the
world as it is perceived to be often makes us aware of gaps in the latter. These gaps represent
unfulfilled wishes. A change in the life space may have the effect of closing one of these
gaps.
If
it does so it will be construed as a "gain" and the fact that the individual has
already
rehearsed in his mind behaviour appropriate to the new, more ideal world may
enable the
transition to take place smoothly.
However it is often the case that the transition from a deficient world to one which is, in
some respects, more "ideal", involves us in changes which were not foreseen. Unexpected
deficits in our ability to cope with the new world give rise to awareness of fresh gaps and
the
situation which we have struggled to reach is found to be full of pitfalls.*
*"Change is not made without inconvenience, even from worse to better", writes Johnson in the Preface to
his
English Dictionary.
Any major
change in the life space is likely to reveal many such pitfalls and to present the
individual
with the need to give up certain assumptions which had become a part of his mode of
coping
with life.
It
is no surprise to find that immigrants to another land often have great
difficulty
in making a successful transition and are frequently disappointed in the size and
number of discrepancies between their ideal model of the "promised land" and the new world
as it is
experienced.
The ability to recognize familiar objects and to orientate oneself within an environment
implies a degree of mastery of that environment regardless of the extent to which the
situation
is actively controlled or altered. There is an "active" component in perception.
A sensory
impression of an object "out there" is compared with previous impressions of similar
objects "in here" and predictions made about the behaviour and characteristics of
the external
object. Many motor acts (e.g. following a moving object with the eyes) are carried
out in order to
facilitate perception and others have, as their goal, the achievement of
certain sensations
which are intrinsically pleasant. In fact sensory and motor phenomena,
feeling and acting are
so intermingled that attempts to separate them do violence to the real
situation. A person is not
the passive recipient of sensations from his life space; he creates
his assumptive world by
reaching out to his environment and sampling it, he reacts to his
life space by moving within
it, to keep it the same or to change it.
The fact that it is necessary to act in order to stay in the same assumptive world means
that any change in the ability to move or perceive the world is likely to cause major changes
in the assumptive world. But the ability to preserve our assumptive world depends on more
than the intactness of our physical apparatus. Knowledge and skills are needed and in the
social world in which we all live it is also necessary to depend upon the abilities of others.
In order to control others we make use of negotiable possessions such as money which
themselves depend upon our ability to render service to others. Taken together these
capacities
and negotiable possessions can be regarded as our "potentialities".
Permission, and often obligation, to make use of potentialities is given by society by the
conferring of status and role (see Parson [8] for a clear account of the relationship between
power, status and authority).
It
follows that major changes in potentialities, negotiable
possessions, roles or status can be expected to lead to the need for major revision of the
assumptive world.
Although it is possible to share parts of the physical world each man's assumptive world
is
unique to himself and no outsider can be sure of its extent. The individual can delineate his
own assumptive world, but even here there are areas which are relatively inaccessible to
introspection. When the assumptive world is made the object of introspection it is treated,
for a time, as a part of the life space. Thus I may speak of "my future" and "my past" as if
these things actually exist. Alternatively some change in the life space may cause me to
"question an assumption"; to objectify the assumption and examine it much as one might
question a witness in a court of law. Such examinations are painful because of the threat
which they represent to the established assumptive world. Moreover there are many
assumptions which are not "open to question" and history is full of examples of the lengths
to which people will go to avoid changing their assumptive worlds.
Whether or not a particular area of the assumptive world is open to introspection depends,
to
some extent, upon the setting and purpose of the introspection. Hence the importance of
rapport in psychotherapy where the aim is to minimize "resistance" to the admission to
consciousness of otherwise unconscious assumptions. Psychotherapy exists to facilitate
change
in the assumptive world and it makes use of the relationship between patient and
therapist as
a "test bed" in which old assumptions can be questioned and new ones be
rehearsed. Insight
occurs when a person recognizes a discrepancy between his assumptive
world and his life
space.
Rochlin [9] has pointed out the part which grief plays in psychotherapy. This is most
obvious, of course, at the ending of therapy when the patient comes to realize the incipient
loss of his therapist but losses also occur whenever a particular aspect of the assumptive
world is found to be discrepant and needs to be given up.
It
has been suggested that the
work of therapy and "grief work" are one and the same thing, the painful reviewing of
redundant assumptions and restructuring of the assumptive world.
The assumptions which are revised in psychotherapy may affect any or most areas of the
assumptive world according to the extent to which therapy is "focal". Other life situations
will tend to require the restructuring of only a part of the assumptive world although,
following a major change in life space, it is more usual for several parts to be affected.
Examples of
events producing lasting changes of catastrophic proportion include
incarceration in a
concentration camp and the development of a fatal illness. In such
situations persons affected
usually attempt to avoid recognition of the true situation. False
hopes are built up and
retained despite glaring evidence of their falsity. This is so often the
rule that Rochlin [9] has
concluded that, "Acceptance and submission are a defence
mechanism". However there is
also evidence that institutions which respect the patients'
defences whilst at the same time
providing them with the opportunity to work towards a
more realistic acceptance of the
situation can enable many to face the prospect of their own
demise and, despite this, to die
in contentment.
In the end it seems that it is the person with the greatest trust in life who is best able to
face death. But Aldrich [10] has described the dramatic improvement which sometimes takes
place in people with long-standing neurotic symptoms when they discover that they are
about
to die and I have come across several examples of this. For these people death may be
seen as
the end of a fruitless struggle to master a life space which is seen as too difficult or
dangerous.
Most changes in life space tend to affect one area of the assumptive world to a greater
extent than others. We shall consider in turn events producing change in personal
relationships, familiar environment, possessions, physical and mental capacities, roles and
status.
It
is not possible here to describe in detail the process of reaction to each of the
possible changes in these areas but I shall try to indicate some of the links between each class of
event.
Changes in personal relationships are, perhaps, the area of greatest interest. They change
at each stage of the life cycle, on going to school, leaving school, marrying, having children,
on
the marriage of children and, in over half of those who marry, on the loss by death,
separation or divorce of the spouse.
Studies of the reaction to loss by death of a loved person have thrown considerable light
on the nature of grief, the painful process of "realization" which normally follows a major
bereavement. The transition takes place from a phase of almost global denial or "numbness"
through a phase of bitter pining and frustrated searching for the lost person (often with a
sense of personal mutilation). This is succeeded by depression and apathy when the bereaved
person finally "gives up" hope of recovering the lost person and a final phase of reorganization
when new plans and assumptions about the world and the self are built up. This sequence
is now
well documented (Lindemann [11], Marris [12], Parkes [13] and Parkes [14]).[See p. xxx for
an assessment of the current status of the phases of grief].
In this context "grief" is seen as a relatively complex process which may follow a "healthy"
course towards a new and satisfactory assumptive world or may become blocked or distorted
in
some way. Two frequent pathological forms of grief are chronic grief (when intense
yearning
and depressive withdrawal fail to resolve in the usual manner) and inhibited or
delayed grief
(when the expression of grief is partially avoided or the need to grieve denied).
In either of
these forms pathological forms of identification sometimes occur and the
bereaved person
develops symptoms resembling those responsible for the death.
Reference must be made at this point to the work of John Bowlby who has spelled out, in
great detail, the way in which young children respond to the loss of a mother or mother
substitute [15, 16, 17]. A great deal of work has now been done in this important field and
few people now doubt the potential dangers involved in lasting loss of a mother and the
other changes in the child's assumptive world that usually accompany this.
Like the bereaved adult the young child whose mother has gone takes time to realize the
loss.
In grief he passes through the same periods of crying and searching followed by
depressive
withdrawal which have been found in the adult and he attempts to mitigate the
pain of grief in
play and at other times by clinging to other persons or toys which become a
substitute for the
lost parent. Children often express bitter anger towards the lost parents at
this time and this
may continue in the case of temporary separations after the mother's
return. The grief of the
separated child has been clearly and painfully illustrated in a succession of films by James and
Joyce Robertson [18, 19, 20]. These were made during periods
of care in hospitals and
residential homes.
As is to be expected the degree of emotional upset is greatest when the change in the
child's life space is greatest and the film of John, an eighteen-month old boy who spent
three weeks in a residential institution while his mother was having a baby reveals, in direct
and poignant manner, the features described above.
Despite the resemblance to adult grief "the mourning processes of childhood habitually
take a course that in older children and adults is regarded as pathological
...
This does not
mean that a crippling of personality is the inevitable result; but it does mean that, as in the
case, say, of rheumatic fever, scar tissue is all too often formed which in later life leads to
more or less severe dysfunction". (Bowlby [17].)
According to Bowlby the bereaved child is particularly liable to defensive processes which
interfere with and distort his relationships with others. He may cling excessively and
ambivalently to others often provoking rejection by the sheer intensity of his demands or he
may reject all close relationships and permit himself only the most superficial of ties. Only
consistent and unconditional affection over a long period of time can reassure the bereaved
child and restore his trust in people and the world.
Anger, as we have seen, is likely to be a prominent feature of the bereavement reactions
of children.
It
is also particularly pronounced in adults when the loss of another is
interpretable as being a rejection or abandonment. This is particularly likely following
separation
or divorce. Far from idealizing the lost partner, as is usually the case following
widowhood,
there is a tendency to denigrate the other and to blame him for the
breakdown of the marriage. This is necessary to enable the divorcee to maintain his own
sense of mastery
of his assumptive world. If the fault lies elsewhere a less radical change is
necessary.
Two things seem particularly likely to predispose to marital breakdown, one is a major
discrepancy between the assumptive worlds of husband and wife, the other is a determined
effort by one partner to persuade the other to change which is interpreted by the other as a
threat to his or her identity. In such circumstances it is seen as less painful to abandon the
marriage than for both partners to change their assumptive worlds in a way which permits
them a tolerable relationship. Either way the transition involves giving up one set of
assumptions about the world and establishing another; grief is the inevitable consequence.
After changes in personal relationships changes in loved possessions are perhaps the most
obvious source of grief. By loved possessions I mean those which we value for their own
sake rather than for their negotiable value. They are the tools with which we exercise our
function in the world and the extensions of ourselves which, after our loved ones we cherish
most dearly. They may include home, garden, car, cat, favourite jewellery, collections of
books or antiques or other objects of "sentimental" value. Insurance will not prevent the
grief which we feel is these things are lost, stolen, or destroyed.
A sense of personal mutilation was described to the writer by a psychiatrist the day after
his
house had been burgled. Not only had he lost valued possessions of which he was very
fond
but his sense of the security of those possessions which remained was shaken. In the
same
way fear of further losses is often reported by bereaved people. Wolfenstein [21], in
describing the reactions of tornado victims has emphasized the frequency with which
unrealistic fears of the disaster recurring are found. This is associated with loss of confidence
in the world as a secure, reliable place.
It
is a characteristic of disasters which have led to the destruction of a home that the
survivors tend to build a new home in the same manner and the same place as the home
which was lost, regardless of opportunities which might exist to build better homes
elsewhere.
It
seems that the amplitude of the change threatened by the disaster is so great
that the
survivor must endeavour to reconstruct his assumptive world exactly as it was
before the
disaster.
The same problems arise when we come to consider other changes in the familiar environment.
Marc Fried [22] in an article entitled "Grieving for a Lost Home" has described the
reaction
of 789 Boston slum dwellers to rehousing. Interviews were carried out before
rehousing and
again two years afterwards. "46 per cent gave evidence", says Fried, "of
fairly severe grief
reactions or worse". Intense pining for the lost home along with psychological, social and
somatic distress and outbursts of anger were typical and there was a
tendency to idealize the
old environment and to denigrate the new. Those inhabitants who,
at the first interview,
showed the most extensive knowledge of the environment, i.e. those
who were familiar with
the largest area of their physical life space, were the ones who were
most grief-stricken after
the relocation.
This applied particularly to older inhabitants who
had been living in the area for many years.
The effects of relocation on old people may be
very serious. To a frail old man or woman her
own home and the presence of a clutter of
familiar possessions helps to preserve a sense of
security and orientation in a world which
moves too fast. Old people, as Cumming and
Henry have shown [23], tend gradually to
disengage themselves from people around them and
the loss of friends and relatives may give
rise to little distress. But they are disturbed by
changes in their physical environment. A
paper by Aldrich and Mendkoff [24] indicates that
this can even affect mortality rate. A
Chicago home for incurables was closed for
administrative reasons. Among 182 patients
who were relocated in other homes 30 were dead
within three months; a mortality rate 5 times greater than expectation. Mortality was highest
among those patients whose grasp on
reality was most tenuous particularly among the 38
whom Aldrich rated as psychotic before
relocation, of these 24 died within a year.
Other changes in the familiar environment which give rise to major alteration of the
assumptive world are emigration and imprisonment. Both of these events have been the
subject of research by social scientists and there is no space here to review the literature
concerning them. Before emigrating the traveller builds up a set of assumptions about the
new conditions he expects to experience. The degree to which these assumptions coincide
with subsequent reality will determine not only the amount of change which he must undergo,
but also its quality and content. The moment of arrival in the new environment, when
the
emigrant becomes an immigrant, is a dramatic and critical time. First impressions are
often
lasting impressions influencing modes of adaptation disproportionately to their
validity or
social importance. This is the period when the assumptive world is most sensitive
to change
and when the migrant is faced with the issues of whether to retain as far as
possible the
components of his former life space, or whether to change them in the light of the differences
he perceives consciously and acknowledges intuitively.
Changes in physical capacities and body image usually go together. Thus disease, aging and
accident tend to produce loss of body parts and impairment of function although in a
particular case one may be more salient than the other. Thus loss of an arm is likely to be
viewed quite differently by a woman and a man. The woman tends to be primarily concerned
with the effect of the amputation on her appearance; the man, on the other hand, is more
concerned with the loss of physical function and working capacity. In selecting an artificial
limb the woman will choose a "cosmetic prosthesis" with a realistic-looking hand even
though
this may be of little use to her. The man on the other hand, chooses a bifurcated hook which,
though it looks nothing like a hand, is much more useful than the "cosmetic
prosthesis".
Most of the physicians and psychiatrists who have written about the psychological
reaction to loss of a limb maintain that "grief" is to be expected. Thus Wittkower [25] says,
"Mourning is the normal emotional reaction", Kessler [26], "The emotion most persons
feel when told that they must lose a limb has been well compared with the emotion of grief
at the death of a loved one", Dembo [27] "A person may mourn his loss", and Fisher [28],
"The reaction to loss of a limb, and for that matter the loss of function of a vital part, is
grief and depression". In none of these studies, however, is it clearly indicated just what it is
that the amputee is mourning for.
An amputee loses a part of his visible body as well as the functions which previously he
could perform by means of the body part. In any particular situation one rather than the
other is likely to be seen as the predominant loss and a cause for grief.
There are many points of similarity between loss of a limb and the loss of a spouse,
although in some ways, the two situations are not comparable. Thus the immediate reaction
to
amputation is often a state of numbness in which physical and mental feeling is blunted,
this is
soon succeeded by a phase of distress in which episodes of severe anxiety occur with
pining
for the lost limb or for those functions which are thought to have been lost. The
amputee is
preoccupied with fears that he will be unable to work or to walk, but at the
same time he
tries to avoid reminders and prefers his friends not to mention his loss.
Depression,
restlessness, tension, difficulty in concentration, insomnia, loss of appetite and
loss of weight
are common symptoms and the amputee tends to be irritable and to go over the
events leading
up to the loss in an attempt to find someone or something whom he can blame.
The so-called "phantom limb" bears much resemblance to the "phantom husband"
described
by most widows. In both cases the lost object is not actually seen but the individual
has the
feeling that it is still present. This sense of presence is associated with a clear visual memory of
the object which may take a long time to fade and which can usually be re-evoked
by an effort
of will.
Whether or not the "phantom limb" has a physiological basis derived from the fact that
the
nerve tracts which once led to the limb are still present, it also has a psychological significance
which would lead us to expect such a phenomenon even if no nerve tracts were
present.
It
comes as no surprise to the psychiatrist to learn that surgical procedures which
interfere with
the continuity of these tracts do not necessarily eliminate the phantom limb.
Chronic pain in the phantom limb, which sometimes follows amputation, may be caused by
complications in the stump. All too often, however, no such physical cause is found and
there
is reason to suppose that psychological factors play a large part in establishing and/or
perpetuating the pain. Older patients who have great difficulty in coping with amputation
and
amputees who have been traumatized by such surgery in the past are particularly likely
to
develop pains of this type. In addition Kolb [29] claims that identification with other
amputees often plays a part. Whether or not phantom pain has a similar origin to the
identification symptoms of bereaved persons which closely resemble symptoms formerly
suffered by the person who has died it does seem to represent one form of pathological
reaction to amputation.
Other difficulties which commonly follow amputations can lead to failure of rehabilitation.
Chronic depression may cause the patient to give up trying to use his artificial limb
so that
he sits at home in an unhappy state of withdrawal. Conversely one may find the person who
denies that loss of a limb is any problem at all. He is the hero of the ward, undertaking tasks
which even an intact person would think twice about. He reacts with
great indignation when
he meets with any limitation to his activity be it a task which he is
now physically incapable
of doing or a person who refuses to ignore his disability.
Similar difficulties have been described following other types of physical disablement. A
recent study carried out at the Tavistock Institute of Human Relations by Fitzgerald [30]
has
revealed the frequency of adjustment problems among the newly blind and once again we find
problems of denial and depression which have many parallels in reactions to other
types of
loss.
Changes in psychological function can have similar effects to changes in physical function
and
psychiatrists are well acquainted with the grief and depression which brain-damaged
patients
go through if they are not so extensively damaged that they are unable to recognize
the nature
of their disability. Patients with loss of memory will sometimes invent a past
which enables
them to avoid realization of the extent of their loss.
It
is almost as if, lacking an assumptive
world they have to create one.
Belonging conceptually in the same class is the situation which arises when circumstances
make it obvious that a person lacks certain psychological attributes which he formerly thought
he possessed. Failure at an examination which one had expected to pass, inability to
perform
adequately in a situation where proper performance is expected, any situation in
which an
individual is brought face to face with deficiencies in his psychological functioning
of which he
was not aware is a cause of grief. To make a satisfactory adjustment the individual must give
up one view of himself and his assumptive world and acquire another, more
realistic one.
Refusal to accept limitations which are obvious to others is seen in boasters
who are
perpetually demanding approval for qualities which they do not possess. Conversely
those who
are found wanting in some respect may give up altogether and become helpless,
depressed and
defeated. Once again we see avoidance and depression as the two main alternatives to
acceptance of reality.
Physical and mental capacities enable a man to exert effective control over his environment.
But a man can also make use of the physical and mental capacities of others provided he has
negotiable possessions (e.g. money) with which they can be bought. Financial losses,
therefore,
result in loss of control over that section of the assumptive world which would
have been
controlled by money. The widow who loses her life savings in a slump is losing a
set of
assumptions about her own future life and maybe that of her children. In this context
it is
important to remind ourselves of the provisional nature of expectations. We build a set
of plans
to enable us to cope with a future which may or may not transpire. We are concerned first
with maintaining that which we possess and we therefore insure against disaster.
Secondly we
are concerned to obtain those things which we lack.* Negotiable possessions
*
Deprivation is a relative thing but, on the whole, once essential needs are met, it is our view of others in
the
society in which we live which determines whether or not we feel deprived. I have no means of
knowing what
is mine by right but I know quite well that if Mr. Jones has a Bentley then I should have
one too. In acquiring
a Bentley I am closing a gap in my assumptive world rather than effecting a change.
From the psychological point of view it might be more of a change to give up the idea of acquiring a Bentley
than it would be to
acquire one. One of the aims of advertising is to build assumptive worlds for people to
live in.
constitute an assurance that our plans are realistic and an insurance against possible disaster.
Without them we feel and are in danger and our plans will have to undergo modification.
It
is for
our assumptions about our lost future that we grieve.
It
is no good being physically and mentally capable if there are no jobs available as many
men
found to their cost during the depression. Unemployment is a form of crippling which
can be
expected to have the same psychological effect as other forms of loss and it may be
that society
should become as sensitive to the damage inflicted on others by psychological
mutilation as it is of
the effects of physical mutilation. The tendency to recoil with horror
from physical violence is
particularly apparent where the punishment of crime is concerned.
Imprisonment or a large fine,
which produce extensive damage to the assumptive worlds of
a man and his family, may be much
greater mutilations than clipping his ears or flogging
him. There are, in my opinion, great dangers
for our society in this tendency to deny the
violence which we employ.
Not that one advocates the restoration of corporal punishment. All that is being suggested
is that we
should become more aware of the mutilation which we inflict in the name of
justice, so that we can
weigh it with greater sensitivity, against the possible benefit to society
of its infliction.
Studies of the psychological effects of unemployment, imprisonment, demotion, retirement and
the transition from school to work are needed to determine the extent to which
these changes in
life space resemble and differ from other types of change. Studies of retirement have already
revealed the depression which commonly attends this event and the need
for adequate preparation
is undoubted. Hill [31] has pointed to the irrelevance of current
methods of schooling as a way of
building an assumptive world which is in accord with the life space of the school-leaver.
It
is no
wonder that school-leavers often feel that they have
been "sold a pup". Difficulties in making the
transition may cause them to turn away from
the adult world as a source of role models, to
become "unattached youths". Much as the widow says, "I don't think of myself as a widow", the
young adult attempts to deny the
fact that he is an adult. The fact that his coevals are going
through the same identity crisis
may mean that they are equally at a loss and so one gets the
formation of social groups who
are united in a collusive endeavour to become nothing, to "drop
out" of society.
The youth who gives up on life and takes a purely negative view of society is necessarily
in a state
of disorganization with all the depression and bitterness which this involves. But
"giving up" is an
important phase of grief, it may be necessary to give up trying to retain a
childish view of the
world as perpetually loving and giving before one can allow oneself to
discover one's capacity to
survive despite competition from fellows and aggression from enemies.
In this, as in so many cases, fear of possible failure in the new life can retard the process
of
relinquishing the old. The appalling magnitude of the change in life space which we
recognize
and the change in assumptive world which we anticipate causes us to draw back,
to "look back in
anger" at the implacable process of change which threatens to overwhelm and destroy us.
One piece of behaviour which, for some time, the writer found puzzling is the frequency
with which
men and women who have lost a limb speak with pleasure of their contacts with people worse off than
themselves. At first it seemed that this reflected the sadistic counterpart
of the envy which amputees
often feel for these who are intact. But on enquiry it is found to be quite a different phenomenon. As
a general rule the person who has recently lost a limb is preoccupied with the problem of his own
future adjustment. Lacking any sound basis for prediction his thoughts range over a variety of
possible models in which he often sees himself as perpetually crippled and helpless. It is only when
he meets someone more seriously mutilated than himself who appears to be coping well and
cheerfully with his disability that it becomes possible for him to look to the future in an optimistic
and realistic
manner.
It is for this reason that people who have successfully come through major transitions in
their lives are often best able to help other individuals who are still caught up in the process
of realization. In this paper it has been necessary to focus attention upon the process of
change which takes place within the individual in response to major changes in his life
space. It is also possible, though outside the competence of the present writer, to extend the
field to include the perspective of the larger units which go to make up society. Major transitions
can affect all members of the family in which they take place, they necessitate the
restructuring of the family unit and their effects may even spread to the work group, and
wider social setting. In the course of transition people are often brought into contact with
others in a similar situation; hospitals can be viewed as communities whose purpose it is to
facilitate the process of psycho-social transition-as can prisons, training establishments
and certain types of emergency accommodation. The concept of the Hospital for the Chronic
Sick as a transitional community has been well studied by Miller 1321. In similar context
Menzies [33] has described how a social system can develop within a hospital which protects
nursing staff from the anxiety of their patients.
Other studies have been concerned with the effects of major change within a large organization.
The activities of the Tavistock team following the tip disaster in Aberfan are an
example of this, but more frequently occurring, if less dramatic, than the Aberfan disaster
are the major changes which occur within industrial organizations as a consequence of
technological change. These have been the subject of several studies by staff of the Tavistock
Institute of Human Relations (Jacques et al. [34], Trist et al. [35], Trist [36] and Sofer t37D.
Finally there is the field of national and international relations. Major social changes and threats of
major change are two of the most important factors by which governments are governed. Whether it
is concerned to bring about change or to preserve the status quo (and issues such as birth control can
be viewed from either perspective) a government needs to be aware of the effects of the psycho-
social processes of transition and the means available to influence them. Just as intra-familial
conflict commonly arises from the reluctance of family members to accept necessary changes in
their life space so some international conflicts arise from the reluctance of nations to accept the
need for change be it change in territory or changes in other parts of their national life space. It may
be that research in the field of psycho-social transitions will eventually have a contribution to make
to the understanding of problems such as these.
To be a suitable area for research a topic should be of theoretical or practical importance, amenable
to study and conceptually discrete. I have said enough in the foregoing pages to indicate the
importance of this field from both theoretical and practical viewpoints. A word more is necessary,
however, in defence of the methodological advantages and conceptual discreteness of the field.
Psycho-social transitions because, by definition, they affect large areas of the assumptive world and
take place over a short period of time, are likely to be readily identifiable. They are often the
subject of official statistics (birth, death and marriage registrations, etc.) and
are therefore
amenable to epidemiological study. Because they comprise the transition from
one relatively
steady state to another they are often open to study before, during and after
the transition
thereby providing the investigator with a natural experiment comparable in
scientific rigour to
that of the laboratory experiment but without the ethical and theoretical
drawbacks of the latter.
Furthermore they often enable us to dispense with that bugbear of
social science research, the
control group, because a person who can be studied before and
after change can be used as his
own control.
Contrary to popular belief individuals who are undergoing psycho-social transitions are usually
aware of their need for help and glad to collaborate in any research which provides
them with an
opportunity to discuss the problems which preoccupy them. They are also
willing, and often
able, to help others in similar predicament and this has emerged as an
important factor
motivating collaboration with any research which is recognizably oriented
to give help.
At the same time it must be recognized that those who are undergoing a major transition
are peculiarly vulnerable to exploitation and easily hurt by insensitive research workers.
It
is,
therefore, especially important that those who undertake this type of work should be more
than ordinarily tactful and capable of using the scientific tools of research in a humane
way.
Because they are aware of the vulnerability of the person in transition others who are
concerned for his welfare tend to adopt a protective attitude and it will be necessary first to
convince them of the benign intentions of the researcher and of his ability to help rather than
to
harm the subject of his research.
"Stress Research" has been criticized for the imprecision of its meaning and the variety
of concepts which it embraces. Clearly there is a danger that Transition Studies, because of
the
variety of situations which can be conceived of as "transitions", may be similarly
criticized. But
this very fact may greatly add to the importance of the field if it can, in fact,
be shown that
there are significant conceptual links between phenomena which, on the
face of it, are widely
diverse.
In order to point up the precision of the basic definition let us consider certain situations
which are excluded from the field of study (though they may be eminently suitable for study
under some other rubric). Maturation, because it is a gradual process of change is not
included, neither is aging, though a particular event which makes an individual suddenly
aware of a change which may have taken some time to occur could be construed as a
psycho-social transition. Frightening situations or transient illnesses which, though they
may
threaten life or cause extreme pain, give rise to no lasting effects on the assumptive
world
are not psycho-social transitions. Neither are lifelong states of deprivation, deformity
or stigma
(though they could, and have, been considered as stressful). Nevertheless the
psycho-social
transitions which occur in a family when a mentally defective child is born or
when a daughter
decided to marry a member of another race falls well within our frame of
reference. Changes
in work methods or the marketing of a new product are unlikely to
represent psycho-social
transitions as here defined unless they produce a major change in the
life space of the population
under study. Finally there is the possibility that adequate
advance planning, and preparatory
training can transform what is potentially a major
change in the assumptive world into quite
a minor transition. This may complicate the
field but it does not invalidate it any more than
the discovery of a means of preventing
rickets has invalidated the concept of rickets as a
disease.
Only further research will tell us how powerful are the theories which will arise out of the
further development of this field.
Acknowledgements- Thanks are due to Dr. John Bowlby and Dr. P. J. M. McEwan for constructive
criticism
of the drafts. The paper was completed in the course of research supported by the Department
of Health
and Social Security and the U.S. National Institute of Mental Health.
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... Alongside the psychoanalytic view of grief, the phase or stage theories (Bowlby, 1980;Parkes, 1971;Kubler-Ross, 1969;Worden, 1999) are probably the most familiar to those working in primary care. These models of grief propose that people bereaved through death or loss go through a number of stages or phases to a point of recovery. ...
... He suggested there were four main phases of grief: numbness; yearning, searching and anger; disorganisation and despair; and reorganisation. Parkes (1971) developed a similar four phase model independently from Bowlby and later developed research collaboration with him. Parkes (1971) suggests grieving was a psychosocial transition because loss and bereavement challenge the assumptive world of the bereaved person who must adapt to their loss. ...
... Parkes (1971) developed a similar four phase model independently from Bowlby and later developed research collaboration with him. Parkes (1971) suggests grieving was a psychosocial transition because loss and bereavement challenge the assumptive world of the bereaved person who must adapt to their loss. Parkes identified numbness, pining, depression and recovery as relevant stages in grief. ...
Thesis
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... Repositioning emerged as the evolutionary task that people had to face after being confronted with a disruption of their old reality caused by the COVID-19 outbreak and the lockdown experience. According to adaptation models (Murray Parkes, 1971;Janoff-Bulman, 1989), challenging conditions force people to rebuild their assumptions about the world and the self, consequently transforming the way they interpret the past and expect the future (Janoff-Bulman, 1989). Rebuilding meaning after a traumatic event (de Jong et al., 2020) has been reported as being fundamental to facilitating adjustment. ...
... Some people did not respect the rules, denying the pandemic situation, others struggled to resume future planning and social relationships, and others still struggled to resume work and asked to be reassigned. Like other stressful events (Murray Parkes, 1971), this pandemic can be conceptualized as a turning point for better or worse psycho-social adjustment. People may have experienced fear, loneliness, uncertainty, loss, and disconnection and may not have been able to make sense of what has happened and to integrate it into their lives. ...
Article
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Background: Anxiety, depression, and post-traumatic stress have been reported among the general population during the first wave of the COVID-19 pandemic. However, the adjustment after the emergency phase remains under-investigated. This study aims to understand the adjustment processes of the population after the emergency phase of the pandemic. Methods: We conducted a grounded theory based on the experience of 24 clinical psychologists who provided extensive support to the population during the pandemic in different Italian regions. Three online focus groups were conducted. The transcripts of the focus groups were analyzed through a process of open, axial, and selective coding. Data collection terminated once thematic saturation was reached. Results: Repositioning emerged as the evolutionary task people were confronted with in the face of a New Reality. Repositioning meant dealing with and integrating unpleasant Emotional Experiences deriving from the lockdown and reopening (i.e., unsafety, emotional exhaustion, loneliness, uncertainty, loss, and disconnection) through different Coping Strategies. Repositioning was facilitated or hindered by contextual and individual Intervening Conditions and led to two Adjustment Outcomes: growth or block. Conclusion: Results suggest that repositioning was the core task people had to face after the emergency phase of COVID-19. Proactive psychological interventions may support the population in repositioning in order to prevent maladjustment and encourage post-traumatic growth.
... En effet, il s'agit plutôt de redéfinir les finalités et les modalités de ces pratiques dans le cadre plus global d'une approche des étapes de la carrière conçues comme de véritables transitions psychosociales. Autrement dit, il s'agit de considérer l'arrêt de la trajectoire professionnelle non plus comme une phase prévisible, strictement normée, standardisée et donc subie mais comme une étape au cours de laquelle le « champ des possibles » est ouvert pour les travailleurs et générant potentiellement des transformations dans leur représentation d'eux-mêmes et de leur rapport au monde (Morsa, & Dayez, 2014 ;Parkes, 1971). En effet nous l'avons souligné, le contexte dans lequel s'inscrit aujourd'hui la gestion de l'arrêt de la carrière offre la possibilité aux salariés de déployer des choix comportementaux actifs notamment en décidant des modalités du retrait de l'activité à différents niveaux (e.g., âge et date du départ, retrait total vs. progressif). ...
Chapter
This chapter will explore the discourses that construct optimistic concepts of growthGrowthand recoveryRecoveryfollowing traumaTrauma/traumatic. The most dominant trauma discourses emphasise the negative symptomology, pathologisation, and negative impact on the lives of those experiencing such events or circumstances.
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Lorsque survient un événement fatidique d’ordre sanitaire, qui affecte l’autonomie de la personne âgée, l’« espace de vie » est remanié, en particulier lorsque le.la conjoint.e endosse le rôle d’aidant. Ce bouleversement est objectif : le quotidien est transformé : les repères routiniers (temps, espaces, relations), les activités, les rôles sociaux, l’intégration d’un nouveau cadre normatif et moral avec un dispositif d’aide à domicile. La fonction d’aidant (avec de nouvelles tâches assumées, le partenariat avec des organismes professionnels) est jalonnée par un planning de soins et d’aides, et par les évolutions pathologiques. Elle occasionne la fréquentation d’espaces et de personnes dédiés à l’accompagnement et au soin. L’aidant abandonne alors certaines activités de loisirs et de sociabilité et connaît un surinvestissement domestique, qui se ré-inverse au placement du conjoint en établissement médico-social.Cette transition biographique du « devenir conjoint aidant » se manifeste aussi par des modifications subjectives, avec un processus réflexif de délibération sur ses choix, un renouvellement du récit de soi, une modification des représentations d’avenir. L’aidant connaît aussi des transformations socio-cognitives en développant des apprentissages expérientiels, des changements de représentations sur la vie domestique et sociale.Pour franchir une telle transition biographique, tous les sujets ne disposent pas des mêmes ressources sociales, matérielles, cognitives et affectives : les entretiens biographiques conduits avec des sujets âgés devenus aidants de leur conjoint malade d’Alzheimer pointent la manière différentielle de surmonter cette épreuve et soulèvent la question cruciale des formes que peut prendre l’accompagnement des aidants, pour compenser ces inégalités.
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Posttraumatic growth (PTG) refers to a positive psychological change that occurs following a seismic and highly challenging life circumstance. An individual who experiences PTG reports posttrauma development that surpasses their baseline level of pretrauma function in various domains. The present systematic review of the current literature aimed to explore factors related to the development of PTG in children and adolescents exposed to trauma. Included studies investigated a range of factors that impact PTG development in youth from five countries: the United States, Israel, China, Japan, and Norway. Studies addressed multiple types of traumatic experiences, including medical trauma, war‐ and terror‐related trauma, and environmental trauma. Findings suggested that factors that impact the development of PTG include the presence of posttraumatic stress symptoms, specifically intrusiveness, and cognitive factors, such as the use of positive reappraisal and deliberate rumination. Many factors demonstrated inconsistencies across studies, such as the impact of age, gender, social support, and parent factors. The findings from this systematic research study encourage the notion that certain clinical intervention strategies, such as deliberate rumination, positive reappraisal coping strategies, and trauma‐informed group therapy, may facilitate growth in trauma survivors. Future research should test if these intervention strategies directly impact growth and whether there is an evidence‐based form of intervention that can assist clinicians in taking a growth‐ and strengths‐based perspective after trauma.
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Bereavement and grief are frequently experienced during the COVID-19 pandemic given widespread mortality. However, losses extend beyond deaths to include cancelled plans and routines, separation from family and friends, and unemployment. It is essential to better understand the multifaceted and complex losses experienced by older adults throughout the pandemic. We analysed 2,587 open-ended survey responses collected online in May to July 2020 from the COVID-19 Coping Study, a mixed-methods study of US adults aged 55 and older. Participants were on average 67 years old (standard deviation = 7.2), over two-thirds female and largely white. Qualitative thematic analysis identified diverse sources of grief, sadness and loss. Themes ranged from death and bereavement to anticipatory grief, loss of agency, cancelled plans and missed milestones, losing social contact and physical touch, health struggles, loss of normalcy and daily routines, and societal and economic woes. The results highlight the varied and highly personal nature of everyday grief and loss among ageing adults during the COVID-19 pandemic. Sources of grief extended beyond death to include both tangible and intangible losses with expectations of long-term consequences. These findings may inform the development of family and community supports, including mental health services, to address complex subjective experiences of grief and loss since the pandemic onset. Interventions are needed to support healing and hope in vulnerable and resilient ageing populations.