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Death Studies
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Resilience Rather Than Recovery: A Contextual Framework on Adaptation Following Bereavement

Irwin N. Sandler , Sharlene A. Wolchik & Tim S. Ayers
a a a a

Prevention Research Center, Arizona State University, Tempe, Arizona, USA Available online: 02 Jan 2008

To cite this article: Irwin N. Sandler, Sharlene A. Wolchik & Tim S. Ayers (2007): Resilience Rather Than Recovery: A Contextual Framework on Adaptation Following Bereavement, Death Studies, 32:1, 59-73 To link to this article: http://dx.doi.org/10.1080/07481180701741343

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Death Studies, 32: 5973, 2008 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print/1091-7683 online DOI: 10.1080/07481180701741343

RESILIENCE RATHER THAN RECOVERY: A CONTEXTUAL FRAMEWORK ON ADAPTATION FOLLOWING BEREAVEMENT

IRWIN N. SANDLER, SHARLENE A. WOLCHIK, and TIM S. AYERS Prevention Research Center, Arizona State University, Tempe, Arizona, USA

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Using a contextual resilience framework, the authors examine the processes whereby bereaved persons change over time. Rather than the concept recovery, the authors propose that the concept adaptation best captures the process of change following bereavement and that the desired outcome of such adaptation is denoted by the term resilience. Adaptation occurs over time and is shaped by environmental and individual level risk and protective factors. By use of a contextual resilience framework, the authors emphasize the central role that personenvironment transactions play versus the heavy emphasis on intrapersonal processes in some other approaches to resilience.

Overview This article will apply a contextual resilience framework to discuss the processes by which bereaved individuals change over time. Using this framework, we propose that the concept of adaptation best characterizes the process of change following the death and that resilience be considered the desired outcome. The framework uses several key concepts from the broader literature on resilience in the face of multiple adversities (e.g., Luthar, 2003; Rutter, 1990) including a conceptualization of positive well being as well as problems as aspects of resilient outcomes, a focus on person and environmental risk and protective factors, and the study of processes of adaptation. Figure 1 presents a pictorial representation
Received 16 June 2006; accepted 15 June 2007. This research was supported by a grant from NIMH R01 MH49155 which is gratefully acknowledged. Address correspondence to Irwin Sandler, Prevention Research Center, Department of Psychology, Arizona State University, Tempe, AZ 85287-6005. E-mail: Irwin.Sandler@aol.com

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FIGURE 1 Contextual resilience model of adaptation following bereavement.

of the relations between these key concepts. From this perspective, the events surrounding the death disrupt the equilibrium of relations between individuals and their environment and threaten their well-being and performance of developmentally appropriate roles. Individuals adapt to this disruption over time by finding new ways to satisfy their basic needs, which affects level of well being and problems and grief. Adaptation is seen as a process that occurs over time and is shaped by environmental and individual-level risk and protective factors. Multiple interrelated domains of outcomes are of interest, including levels of problems (including mental health problems, substance abuse, and physical illness), positive well being (including competent role performance and life satisfaction) and grief. We refer to our model as a contextual resilience framework to emphasize the central role that personenvironment transactions play versus the heavy emphasis on intrapersonal processes in some other approaches to resilience. The article will first discuss the concepts in our contextual resilience framework in somewhat greater depth. We will then briefly discuss similarities and differences between the contextual resilience framework and other models of adaptation after bereavement, and indicate why we prefer the concept of resilience to that of recovery. Finally, we will summarize some of the findings from our research with parentally bereaved children to illustrate

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how this framework has guided our theoretical and intervention research. Major Concepts in the Contextual Resilience Framework
RESILIENT OUTCOMES

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A major research issue for those studying response to adverse experiences is to explain differences in adaptation: Why do some people adapt well following exposure to adversity whereas others adapt poorly? Positive versus negative adaptation is conceptualized broadly to include multiple domains of functioning including levels of problematic functioning (e.g., mental health problems, substance use, and physical health problems) as well as lower levels of positive functioning (e.g., life satisfaction, growth, and developmentally competent role performance; Luthar, 2003; Masten & Coatsworth, 1998). In addition to the traditional outcomes studied in resilience literature, for bereaved individuals there is special interest in understanding problematic versus healthy grief (Prigerson & Jacobs, 2001; Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002). The focus on positive as well as negative outcomes distinguishes a resilience approach from other approaches that focus more narrowly on pathological outcomes (e.g., depression and traumatic grief).
CUMULATIVE INDIVIDUAL AND ENVIRONMENTAL RISK AND PROTECTIVE FACTORS

One approach to addressing resilience has been to identify risk and protective factors that predict differential functioning for those exposed to adversity. Risk and protective factors can be at the individual, family, community, or cultural level. A robust finding that has emerged from this work is that of cumulative risk and protection; resilient outcomes are best predicted by the cumulative effect of multiple risk and protective factors rather than any single factor (Wyman, Sandler, Wolchik, & Nelson, 2000; Sameroff, Gutman, & Peck, 2003). As applied to the bereaved, positive and negative outcomes are best predicted not from any single factor (e.g., caregiver mental health, traumatic death) but from the accumulation of multiple risk and protective factors that may proceed or follow the death (e.g., quality of relationship with caregiver, individuals beliefs about control over life events).

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From an ecological perspective, individuals are seen as nested within families, which are in turn nested within communities and cultures (Sameroff & Fiese, 2000; Wyman et al., 2000). These different levels are seen as organized and thus having a level of stability but also as changing over time, as the organization accommodates to integrate new input. An ongoing dynamic process of mutual influence occurs in which individuals are influenced by changes in their families and changes in the individual lead to changes in the family. These processes are embedded within communities and culture, which also may be altered by external economic, social and technological changes (e.g., globalization, migration, war, natural disaster, rapid and inexpensive communication technologies). Culture provides a framework for defining what outcomes are considered positive or negative.
FOCUS ON PROCESSES OF ADAPTATION

There is an increasing emphasis in resilience theory and research in moving beyond prediction of adaptation to understanding the processes underlying adaptation. Processes of adaptation can be studied using both quantitative and qualitative approaches. Alternative models of theoretical processes that have been tested using quantitative models include mediation, moderation, and compensatory main effects of risk and protective factors (Luthar & Cicchetti, 2000; Sandler, Wolchik, Davis, Haine, & Ayers, 2003). Mediation models propose that the effects of one process (e.g., parenting) on another (e.g., grief) occur through a third intervening variable (e.g., individuals level of security of attachment). Moderation models argue that a pre-existing factor (e.g., gender, age) changes the effect of one variable (e.g., postbereavement stressful events) on another (e.g., depression). Compensatory main effect models propose that two variables (e.g., coping and caregiver-child relationship quality) have independent, direct effects on a third (e.g., depression). Underlying these models are theories of the mechanisms by which these effects occur. For example, Lazarus and Folkmans (1984) transactional model of coping has been widely used to study adaptation to adversity, including bereavement (Stroebe & Schut, 2001). In our research with bereaved children, we have proposed that risk and protective factors affect resilient outcomes through a common pathway, their influence on the satisfaction of

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individuals basic needs and developmental competencies (Sandler, 2001). The proposition that stressors affect children by interfering with accomplishment of developmental competencies has been emphasized in the literature on resilience (e.g., Masten & Coatsworth, 1998). The proposition that stressors have their impact by threatening satisfaction of individuals needs and goals is derived from Lazaruss (1999) theory that stress follows from a subjective appraisal of events as threatening the individuals values, goals, and so on (Lazarus, 1999). Although for each individual goals are best understood by a deep understanding of their context and commitments, broad categories of goals that are common across individuals can be identified (e.g., Maslow, 1954; Deci & Ryan, 1985). Similar to Skinner and Wellborne (1994), we believe that children actively construe themselves in relation to their social context around these goals through internal belief systems or selfsystem processes. Our research with bereaved children has focused on three self-system processes: sense of social relatedness to ones primary caregivers, sense of control or efficacy, and sense of selfworth. However, we readily acknowledge that other belief systems may be important for some children (e.g., need for physical safety). We proposed models in which adverse changes in childrens environment threaten these self-system processes and supportive resources mitigate these effects through compensatory effects to bolster these self-systems processes. From this perspective, resilient adaptation following bereavement involves reorganization of the individual and social environmental systems to enable positive satisfaction of basic needs and developmentally competent role performance, (which in turn leads to low levels of problems and high levels of well-being and healthy grief) and promote current mental health, meeting the challenging tasks of later developmental periods.
SIMILARITIES AND DIFFERENCES OF THE CONTEXTUAL RESILIENCE FRAMEWORK WITH OTHER MAJOR MODELS OF ADAPTATION OF THE BEREAVED

Our model of contextual resilience shares many features with Balks (2004) description of recovery as redefining and reintegrating the self into life. Although we agree that reintegrating oneself into life is a central task for the bereaved, we prefer the term resilience to recovery for two reasons. First, the term resilience ties the

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bereavement literature with a rich body of research on adaptation to other major adversities. This broader resilience literature includes many concepts (described above) that we believe will be very useful for studying bereavement, such as the notion of cumulative risk and protection, the focus on understanding the processes underlying adaptation, and a broad conceptualization of outcomes as including positive functioning as well as problems. Second, the term recovery is often interpreted by professionals as well as the public to imply a medical metaphor, in which grief is a disorder from which one recovers to reestablish a pre-existing state of health, rather than as a normal process of adaptation and change following loss. Although Balk rightfully pointed out several positive connotations of the term recovery, the reactions he described from professional colleagues to the use of this term illustrate the negative surplus meaning carried by the term recovery. Like the two-track model and the dual process model (Rubin & Malkinson, 2001; Stroebe & Schut, 1999), the contextual resilience model focuses on adaptation to the changes that occur in the post-death environment and the loss of the person who died. Although coping with these changes is an integral facet of each model, the proposed contextual resilience model places a greater emphasis on the functionof coping to enable the person to adapt both behaviorally and cognitively to environmental stressors and feelings of loss or grief in ways that satisfy motivational needs and facilitate developmental competencies. For example, if events are uncontrollable, the person may use strategies to establish a sense of secondary control (e.g., allying with powerful others or obtaining interpretive control by developing an effective understanding of the stressors; Rothbaum, Weisz, & Snyder, 1982). If the primary source of intimate connection has been lost, lossoriented coping is used to think about the deceased in ways that maintain a positive sense of continued connection and social support-seeking coping is used to achieve a sense of security of intimate social connections with others. Like the meaning making perspective (Neimeyer, 1998), a contextual resilience framework shares the view that meaning is an interpersonal as well as an intrapersonal process that is anchored in cultural belief systems, roles, and rituals. The contextual resilience approach views meaning in relation to the satisfying

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needs and goals in interaction with the post-death environment, such as maintaining a sense of worth, security, and control. For example, continuing bonds (Klass, Silverman, & Nickman, 1996) with the deceased would be viewed in terms of their function of transforming the manner in which the relationship satisfied needs, such as emotional support and validation of worth, from actual interactions to a representation of the relationship after the death. The contextual resilience model is also compatible with family systems and interpersonal perspectives (Nadeau, 2001; Shapiro, 1994). In these models, family relationships and ongoing changes following the death are viewed as playing central roles in affecting outcomes for the bereaved, which are to a great extent mediated through socially constructed belief systems and world views. Like these models, we view family and environmental processes as nested within broader cultural frameworks, although our own research (briefly reviewed below) has focused on the interrelations between individual and family processes and outcomes. The family systems and interpersonal models go beyond the current formulation in describing how family dynamics influence adaptation of the bereaved, whereas the contextual resilience model emphasizes individual coping processes and the linkage between family variables and satisfaction of the individuals needs. The emphasis of the contextual resilience model on person environment transactions following the death as causal mechanisms in adaptation contrasts with the emphasis on the nature of the events (objective or subjective) surrounding the death per se in leading to problematic outcomes in a trauma theoretical approach. From a trauma perspective, traumatic circumstances surrounding the death interfere with the tasks of grief (Cohen et al., 2002), which in turn lead to problematic outcomes such as complicated grief. The central theoretical mechanism leading to problem outcomes in trauma theory is the interference of traumatic memories with necessary grief tasks, so that the death event per se and how it is interpreted are of primary concern in understanding outcomes. Our contextual resilience framework views traumatic memories as only one of many processes influencing adaptation and places greater focus on the role of the postbereavement context in meeting childrens needs than does a trauma model.

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Application of a Contextual Resilience Model to the Study of Resilience of Parentally Bereaved Children Using a contextual resilience model, we have conducted a program of research that has tested alternative theoretical models by which risk and protective factors following the death lead to resilient or pathological outcomes (Sandler, Wolchik et al., 2003). Below, we review some of these studies with parentally bereaved children to illustrate the linkages between the contextual resilience framework and theoretical and intervention studies. The objective of our research has been to identify potentially malleable risk and protective factors that could be targeted in interventions to prevent problem outcomes for parentally bereaved children (Sandler et al., 1997). Our research has focused largely on risk and protective factors at the level of the child and family. An essential step in this work involved developing reliable and valid measures of potentially important risk and protective factors, such as bereavement-related stressors (West, Sandler, Pillow, Baca, & Gersten, 1991), parenting (Kwok et al., 2005), and processes of coping with stressful events (e.g., coping behaviors, Ayers, Sandler, West, & Roosa, 1996; threat appraisals of stressful events, Sheets, Sandler, & West, 1996; coping efficacy, Sandler, Tein, Ayers, & Wolchik, 2000), self-system processes and indicators of adaptation outcomes that may be affected by these processes (e.g., fear of abandonment, Wolchik, Tein, Sandler, & Ayers, 2006; grief, Kennedy, Sandler, Millsap, Ayers, & Tein, under review). Lin and colleagues (Lin, Sandler, Ayers, Wolchik, & Luecken, 2004) used several of these measures to test a multivariate model of the best combination of risk and protective factors at the level of the child and family that differentiated bereaved children who did and did not have serious mental health problems. Children rated as above the clinical level on standardized measures of mental health problems as rated by either parents, children, or teachers were considered to have serious mental health problems. Consistent with a cumulative model of resilience, multiple factors contributed to discriminating children with and without serious mental health problems: family-level variables of caregiver warmth and discipline as rated by both caregiver and child, caregiver mental health problems, and child-level variables of coping efficacy and

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appraisals of threat associated with the two most stressful event experienced in the prior month. In a separate sample, Haine, Ayers, Sandler, Wolchik, and Weyer (2003) found support for self-esteem and control beliefs as additional individual-level protective resources for parentally bereaved children. Findings from several other studies have supported the role of environmental processes following the death, particularly postdeath stressors, caregiver mental health problems, and parenting (Haine, Wolchik, Sandler, Millsap, & Ayers, 2006; West et al., 1991). Kwok and colleagues (Kwok et al., 2005) found support for a mediational model in which caregiver mental health led to decreases in positive parenting which in turn led to increased mental health problems. Our findings on the impact of post-death environmental risk and protective factors are consistent with findings of several other research groups who have studied the impact of parental bereavement on adaptation in childhood as well as adulthood. For example, researchers have consistently shown that quality of parenting by the surviving caregiver (e.g., Partridge & Kotler, 1987; Raveis, Siegel, & Karaus, 1999) and stressful events (e.g., Thompson, Kaslow, Price, Williams, & Kingree, 1998) are related to mental health problems in children as well as adults who experienced parental bereavement in childhood. As a further test of our theoretical model of adaptation of parentally bereaved children, we examined a model in which stressors and positive parenting would affect childrens self-system beliefs, which in turn would affect their internalizing and externalizing problems (Wolchik et al., 2006). In the cross-sectional test of this model, we found support for fear of abandonment and self-esteem to mediate the effects of stressful events on childrens mental health problems, and for fear of abandonment and coping efficacy to mediate the effects of positive parenting on childrens mental health problems. In an even more stringent test of the model, we used a prospective longitudinal design in which stressors and positive parenting at Time 1 were predicted to affect self-system variables three months later, which in turn were expected to impact mental health problems eleven months later. We found support for fear of abandonment to mediate the effects of stressful events on internalizing and externalizing problems over eleven months later. We conceptualized fear of abandonment as an indicator of a self-system process in which the security of the attachment with

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the caregiver is threatened. Given the magnitude of the interpersonal losses that occur with parental death, this self-system process is likely to be particularly impactful for parentally bereaved children. A more recent study that found that fear of abandonment also mediated the relations between parenting and stressful events and childrens grief provided further evidence of the salience of the fear of abandonment construct for these children (Wolchik, Ma, Tein, Sandler, & Ayers, 2007). Parental death is seen as having long-term effects on development through a cascading process by which changes in the individual and environment at one stage of development influence later changes in the individual and environment. Brown and colleagues (e.g., Harris, Brown, & Bifulco, 1986) longitudinal research on the development of depression in adult women provides an interesting illustration of a cascading process for girls who experienced the death of a parent in childhood. Their data showed that lack of care from the surviving caregiver following the death led to a sense of helplessness in girls and exposure to multiple stressful events in the family (e.g., conflict), which then led girls to become involved with anti-social peers and develop unstable attachment=romantic relationships. Over time, bereaved girls experienced increasingly serious stressors, such as premarital pregnancy. Poor coping with these adversities led to unsupportive and unstable romantic relationships, exposure to additional serious adversities, and vulnerability to depression in adulthood.
IMPLICATIONS OF THEORY FOR INTERVENTIONS TO PROMOTE RESILIENCE

Theories of change following bereavement can guide the development of systematic efforts to help the bereaved. However, all theoretical models run the risk of being overly prescriptive, so that providing the help that is theoretically needed takes precedence over providing the help that enables bereaved individuals to adapt in a way that meets their individual needs and goals. For example, models that prescribe the necessary stages or tasks of grief (Wortman & Silver, 1989) that require expression of negative or positive affect or specify a set time period for normal recovery may not meet the needs and capabilities of some bereaved individuals. The antidote to this overly prescriptive role of theory is to think of bereaved individuals as active agents who are aware of their experiences, capabilities and needs and who can benefit from

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support, information, guidance, and skill instruction to find ways to meet these needs. Theoretical models are useful to articulate the processes that lead to resilience. Because processes that are theorized to be helpful may operate in unexpected ways, research is needed to test the hypothesized relations. Building on findings from these studies, programs to systematically promote the processes that relate to positive outcomes can be designed and the efficacy of these programs can be evaluated. Our research on parentally bereaved children illustrates the process of developing and evaluating a theory-based intervention. We did not start with a formal theory of resilient adaptation, but with a general model of cumulative risk and resilience, in which multiple factors at the individual and social environmental levels lead to resilient outcomes. From an intervention perspective, a cumulative risk and protection model provides multiple potential routes by which the strengths of the family or the individual might be mobilized. As described above, our research found support both for risk and protective factors at the family (e.g., parenting, caregiver mental health problems, stressful events) and individual (e.g., coping efficacy, threat appraisal, control beliefs, self-esteem) levels as being related to mental health problems in bereaved children. We designed an intervention program to change each of these processes and tested its efficacy using a randomized experimental trial (Sandler, Ayers et al., 2003). The program was effective in changing many of these risk and protective factors and in reducing mental health problems of girls 11 months following completion of the program. We also demonstrated that the program improvements in mental health problems in girls were accounted for by changes in multiple processes at the level of the family (e.g., increasing positive parenting, reducing negative life events) and individual child (e.g., reducing inhibition of emotional expression, increasing positive coping, decreasing unknown control beliefs, and reducing threat appraisals; Tein, Sanders, Ayers, & Wolchik, in press). These findings not only provided support for program efficacy but also provided further evidence for the role of these family and individual level risk and protective factors in influencing outcomes for bereaved children. Furthermore, the findings opened up several new and important questions, including Why were the

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program effects to reduce mental health problems stronger for girls than boys? and How do the effects of the program change over time? These questions will be addressed through further research that is guided by our contextual resilience model of adaptation to parental death. References
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