The mourning process in chronic illness
IMAO, Mayumi(Nagoya University)

Chronic illness
Defining “chronic illness” is complex. The term is often mentioned incontrast to “acute illness”. Generally, the term refers to an incurable illness forwhich a course of treatment has not yet been established. A person with chronicillness may cycle between periods of mild improvement and relapse. Althoughchronic illness does not itself cause death, it is a lifelong affliction. Diabetes,
asthma, epilepsy, and kidney problems are examples of chronic illnesses.
Psychological aspect of patients
Chronically ill patients must continue to live in spite of their ailments.
In addition to physical implications, chronic illnesses may have psychologicalrepercussions, including such negative feelings as helplessness, low self-esteem,anxiety, and depression. A person diagnosed with a chronic illness knows that hisor her illness is ‘forever’. Thus, an examination of the psychological aspects ofchronic illness must be undertaken in order to holistically address patients’ wellbeing.
Focusing on mourning work
This study examined the psychological dimensions of patients’ chronicillness, using the concept of mourning. Chronic illness is a form of the “objectloss”. Patients with chronic illness undergo various changes, including such “objectlosses”, as bodily functions, social constraints, etc. Patients accept their losses bygoing through the mourning process. Psychological reconstruction, as a function－96－

of the mourning process would be the basis for patients’ efforts to adjust to life withchronic illness.
Two models of the mourning process
There have been numerous studies on mourning work and there are twomajor models of mourning work in the field of disabilities and chronic illnesses.
These two models contradict each other, but both contend that the mourning
process is composed of five stages: shock/impact, denial, emotional confusion,
effort at resolution/focusing outward, and acceptance/closure.
The first model, often called the “stage” or “linear” model, is pervasive
among researchers and practitioners. According to this model, the five stages
appear in the order listed above and the mourning process progresses linearly. In
this model, the process will come to the end in the span of one or two years. The
second model is called the “chronic sorrow model” or the “cyclical model”. In thismodel, the five stages are divided into two phases. Phase I include the first threestages that are repeated cyclically.

Phase II includes the other two stages.

Proponents of this model suggest that disabled or chronically ill people seldom
progress from Phase I to Phase II. Rather, they go through a cyclical process
within Phase I. .
The latter model has been presented as antithetical to the former model,
particularly in the realm of disabilities or chronic illnesses. Because disabilities orchronic illnesses are permanent, people with disabilities or chronic illnesses
inevitably confront stressors like deterioration and difficulties throughout their lives.
Their grief does not diminish or resolve, so the mourning process never ends andthe patients cycle between the first three stages.
Examination of two existing models
The “chronic sorrow/cyclical model” is important because it is based on
the characteristics of chronic illness. However, no studies have examined the－97－

relationship of both models to chronic illness.

This study examined theapplication of both models to chronically ill peoples’ life stories, as related after theonset of their illnesses.
Fourteen people with chronic kidney disease participated in the study. Their ages
ranged from 19 to 34, and there were six males and eight females. In recognition ofpossible age or developmental differences in coping with chronic illness, this study
focused on specific demographic population, that of young adults.
Discussion
Two patterns of mourning could be observed in participants’ life stories;A) stages of shock/impact, emotional confusion, and effort for resolution/focusing
outward appear in order; B) stages of denial and emotional confusion appear inorder.
(1) Nature of the mourning process: Linear or cyclic?
This study found that the five stages of mourning did not progress in a
linear fashion. Stages recurred in the face of major life events or deterioration.
Several stages coexisted and overlapped in some cases. These results were morecongruent with the chronic sorrow model or cyclical model than the linear model.
However, the shift from Phase I to Phase II occurred among 71.4% ofparticipants in this study. Recurrence of stages was also not limited to the firstthree. These results suggest that neither model were applicable to chronic illness.
But some characteristics of both models could be included. Namely while themourning process has characteristics of chronic sorrow/cyclical model, it develops
stage by stage towards “acceptance/closure” when macroscopically viewed.
(2) Positive function of “denial”“Denial”, the second stage in the mourning process, is a temporally andstrong psychological defense mechanism that deals with acute emotional crisis at－98－illness onset. It buffers initially the shock by denying or refusing the illness.
“Denial” is seen as a negative stage because it may delay or stagnate the mourning
process, and can become pathological if a person does not move beyond it.
The “denial” observed in this study were milder than defined and seemed
to be a particular attitude or strategy towards the chronic illness rather than
temporally and strong defense mechanism. Chronically ill people must deal witheveryday affairs, such as domestic duties, family matters, school, work, etc. Thismeans that their illnesses cannot always be the centre of attention. In such cases,“denial” is effective because it temporarily pushes aside the illness and enables thesufferer to deal with other priorities. This research suggests that clinicians should
pay more attention to the positive function of “denial”.
(3) Closure in the mourning process“Acceptance/closure”, the final stage of mourning, did not occur for thisstudy’s participants and is incompatible with the linear model which specifies its
occurrence within one or two years. Most studies about mourning have focusedexclusively on bereavement. In the case of chronic illness, the mourning process
cannot be completed in such a short time span. Longtime adjustment is needed
for chronic illnesses and the process of mourning inevitably becomes longer than it
is for bereavement.
A conceptual issue surrounding “acceptance/closure” should be noted.
It has been pointed out that the definition of “acceptance/closure” is too ambiguous.
However, this is a difficult issue to reconcile especially in the case of chronic illness.
Different people respond to chronic illness differently, so a rigid definition ofacceptance vis-à-vis chronic illness seems inappropriate. In this study, there werediversities among participants with regards to “effort at resolution/focusingoutward”, the stage before “acceptance/closure”. Namely, each participant tried toconstruct the meaning of his/her illness differently. We should reconsider themeaning of “acceptance/closure” in chronic illness, paying attention to such－99－

diversity and individuality.
Conclusion
In this study, the process of mourning in chronically ill people did notshow either model of mourning to be a perfect fit. An alternative model adapted
to chronically ill people is needed.
Chronic illness does not bring immediate death, but rather requires
constant attention and lifelong care. The prognosis for chronic illnesses is unclear.
Aggravation or developmental crises may necessitate a confrontation of the losses
caused by the illness.
The results of this study show that “ambiguity” accompanies chronicillness. Therefore, comprehensive analysis of the mourning work of chronicallyill people requires an examination of “ambiguity”. Accounts of the longtimeprocess of adjustment to chronic illness are also needed, as is consideration ofindividual development. In constructing an alternative model of the mourning
process, we should also consider developmental problems. Viewing mourning
processes as an individual developmental process will help us better understand andcare for patients.
References
Imao, M. (2004). The process of mourning work in chronic illness: examination ofstage and chronic sorrow models. The Japanese Journal of Developmental
Psychology, 15, 150-161.

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