Theory

Middle-Range Theory Of Chronic Sorrow

Georgene G. Eakes, Mary 1. Burke, Margaret A. Hainsworth

Purpose: To introduce a middle-range nursing theory of chronic sorrow that presents this
sorrow as a normal response to ongoing disparity due to loss. Chronic sorrow is the periodic
recurrence of permanent, pervasive sadness or other grief related feelings associated with a
significant loss. The theory provides a framework for understandingand working with people
following a single or ongoing loss.
Organizing framework: The model of chronic sorrow includes antecedents, trigger events,
and internal and external management methods.
Scope: Theory is useful for analyzing individual responses of people experiencing ongoing
disparity due to chronic illness, caregiving responsibilities, loss of the ”perfect” child, or
bereavement.
Sources: The theory was developed using concept analysis, critical review of research, and
validation in 10 qualitative studies of various loss situations.
Conclusions: Chronic sorrow has been shown to explain the experience of people across the
lifespan who encounter ongoing disparity because of significant loss. Nurses need to view
chronic sorrow as a normal response to loss and, when it is triggered, provide support by
fostering positive coping strategies and assuming roles that increase comfort.

IMAGE: JOURNAL OF NURSINGSCHOLARSHIP, 1998; 30(2), 179-184.01 998, SIGMA THETA

TAUINTERNATIONAL.

[Key Words: grieymourn; loss; chronic sorrow1

c
* * *

hronic sorrow was introduced into the literature more than
30 years ago to characterize the recurring waves of grief
observed in parents of children with mental deficiencies
as they struggled to cope with the loss of a “perfect child”
(Olshansky, 1962). The pervasive, recurrent sadness
Olshansky characterizedas chronic sorrow was viewed as a normal
response to disruptions of anticipated normalcy.
Subsequent research validated the occurrence of chronic
sorrow among parents of mentally or physically disabled young
children and expanded the emotions commonly experienced to
include not only sadness and sorrow, but also fear, helplessness,
anger, frustration, and other feelings characteristic of grief
(Burke, 1989; Damrosch & Perry, 1989; Fraley, 1986; Hummel
& Eastman, 1991; Phillips, 1991; Seideman & Kleine, 1995;
Wikler, Wasow, & Hatfield, 1981). Concluded in these studies
was the idea that the never-ending nature of the loss of the
“perfect” child prevented resolution of grief and precipitated
periodic episodes of re-grief or chronic sorrow.
Research undertaken by the Nursing Consortium for Research
on Chronic Sorrow (Eakes, Hainsworth,Lindgren, & Burke, 1991)
has expanded the relevance of the concept to individuals
experiencing a variety of loss situations, as well as to their family
caregivers (Burke, 1992; Eakes, 1993; Eakes, 1994; Eakes, 1995;
Eakes, Burke, Hainsworth, & Lindgren, 1993; Hainsworth, 1994a;
Hainsworth, 1994b; Hainsworth, 1995; Hainsworth, Burke,
Lindgren, & Eakes, 1993; Hainsworth, Eakes, & Burke, 1994;
Hainsworth, Busch, Eakes, & Burke, 1995; Lindgren, 1996). Our
middle-range theory of chronic sorrow was inductively derived and
validated through a series of 10 qualitative studies conducted by
members of the Nursing Consortium for Research on Chronic
Sorrow (NCRCS) and a critical review of existing research.
According to Walker and Avant (1993, in concept analysis the
attributes or defining characteristics of a particular idea are
examined. Moreover, this defining is an essential step in theory
development. Analyses of the concept of chronic sorrow
documented in the literature (Lindgren, Burke, Hainsworth, &
Eakes, 1992; Teel, 1991) provided the foundation upon which
the theoretical model of chronic sorrow was built. Defining
characteristics of chronic sorrow, as noted by Lindgren and
colleagues (1992, p. 3 l), include the following: (a) A perception
of sadness or sorrow over time in a situation with no predictable
end. (b) Sadness or sorrow that is cyclic or recurrent. (c) Sadness
or sorrow that is triggered internally or externally and brings to
mind a person’s losses, disappointments, or fears. (d) Sadness
or sorrow that is progressive and can intensify.
Ceorgene C. Eakes, RN, EdD, Beta Nu, is a Professor East Carolina Uni-
versity School of Nursing, Greenville, NC. Mary 1. Burke, RN, DNSc,
Delta Upsilon-At-Large, is a Professor and Margaret A. Hainsworth, RN,
PhD, CS, Delta Upsilon-At-Large, is a Professor, both are at Rhode Island
College Department of Nursing, Providence, RI. A number of the NCRCS
studies were supported by funding from Beta Nu chapter, Sigma Theta Tau
International and by Rhode Island College Faculty Research grants. Cor-
respondence to Dr. Eakes, School of Nursing, East Carolina University,
Greenville, NC 27858-4353 or E-mail eakesg@mail.ecu.edu
Clinical Sidebar: Susan R. Redding, RN, CRNH, Beta Nu, i s a graduate
student at East Carolina University School of Nursing, Greenville, NC,
and an end-of-life-care hospice nurse.
Accepted for publication October 3, 1997.

Volume 30, Number 2, Second Quarter 1998 /mage:/ournal of Nursing Scholarship 179
Chronic Sorrow Theory
In addition to setting forth the critical attributes of chronic sorrow,
analyses of the concept provide descriptions of events and
circumstances antecedent to the occurrence of chronic sorrow.
These events include involvement in the trajectory of a chronic
illness or disability , either as the one affected or as a caregiver; a
recognized negative disparity between the past and present; and the
occurrence of events that bring the disparity into focus (Lindgren
et al., 1993;Teel, 1991).
Although the process of concept analysis is formal and rigorous,
Walker and Avant (1995) warn that results are always tentative.
Indeed, findings from research studies conducted by the Nursing
Consortium for Research on Chronic Sorrow have not consistently
demonstrated progressivity of the emotions associated with chronic
sorrow (Eakes, 1993;Eakes et al., 1993;Eakes, 1995; Hainsworth,
Burke, Lindgren, & Eakes, 1993; Hainsworth, 1994b; Hainsworth
et al., 1994; Hainsworth et al., 1995). Rather, the potential for
progressivity and intensification of chronic sorrow over time has
been identified.
Further modification of the defining characteristics of chronic
sorrow has resulted from recent NCRCS research demonstrating
evidence of chronic sorrow among people who have experienced
a single loss event rather than an ongoing loss (Burke, 1994;Eakes,
1994; Hainsworth, 1994a). Therefore it is the ongoing disparity
created by the loss experience, rather than the ongoing nature of
the loss situation as originally hypothesized, that is antecedent to
chronic sorrow. Recognition of the common denominator of
disparity, the difference between the current reality and the desired,
was a major breakthrough in that it explains the occurrence of
chronic sorrow in both ongoing and circumscribed loss situations.
Chronic sorrow has been rethought based on these research findings
and is now defined as the periodic recurrence of permanent,
pervasive sadness or other grief-related feelings associated with
ongoing disparity resulting from a loss experience. Chronic sorrow
is viewed as a normal response to ongoing disparity associated with
a loss situation; indeed, research has shown that it is universally
experienced by those who suffer a signifcant loss. Normalization
of the process of chronic sorrow in no way diminishes the validity
or intensity of the feelings experienced.
Overview of the Chronic Sorrow Model
Our theory of chronic sorrow offers an explanation of how people
may respond to both ongoing and single loss events. The model of
chronic sorrow not only offers a framework for understanding
responses to various loss situations, but also offers a new way of
viewing the experience of bereavement. The model of chronic
sorrow is in Figure 1.
Chronic sorrow experience is cyclical and continues as long as
the disparity created by a loss remains. Chronic sorrow is viewed
as a normal response to an abnormal situation. While episodes of
sadness abate and individuals do go on with their lives, as long as
the disparity created by the loss exists, chronic sorrow is likely to
be periodically experienced. This periodic return of grief is
experienced by individuals and caregivers whose anticipated life
course has been disrupted. Chronic sorrow is characterized as
pervasive, permanent, periodic, and potentially progressive in
180 1mage:journalof Nursing Scholarship
I' - I
F? '
I
Figure 1. Theoretical Model of Chronic Sorrow
nature. These attributes are reflected in the words of mother whose
child had died:
The pain will never completely go away, but like anything else, you just
learn to live with it. You learn how to live with an amputated limb. You
learn how to live with a broken heart (Burke, 1994).
As shown in the model (Figure l),the experienceof chronic sorrow
may occur subsequent to a loss experienced at any point across the
life span.
Chronic sorrow is clearly differentiated from prevalent time-
bound models of grief and from pathological grief and depression
(Burke, Hainsworth, Eakes, & Lindgren, 1992; Lindgren et al.,
1992; Teel, 1991). Whereas traditional grief theorists (Bowlby,
1980 Lindemann, 1944) purport that resolution is the necessary
and normal outcome of grief reactions associated with loss, the
theoretical premise of chronic sorrow allows that people may
periodically re-experience the pervasive sadness or other grief-
related feelings that occur when initially confronted with the loss.
Although each episode of sadness abates over time, circumstances
or situations in which the individual is confronted with the disparity
created by the loss trigger recurrence of the grief-related feelings.
Because of the cyclical nature of chronic sorrow, periods of
happiness and satisfaction are interspersed with episodes of re-grief,
thereby preventing the grief from becoming incapacitating (Burke
et al., 1992; Copley & Bodensteiner, 1987; Lindgren et al., 1992;
Teel, 1991).
The need for alternative models of loss is widely recognized.
Moreover, there is growing recognition that the unique nature of
losses, both real and symbolic, that accompany chronic illness and
disability prevents closure or resolution (Davis, 1987; Stephenson
& Murphy. 1986; Worthington, 1994). Interestingly,Quint's (1969)
definition of chronic illness as one that is progressive, periodic, and
permanent mirrors the experience of chronic sorrow.
Cyclical models of grief that allow for the feelings of grief to be
revisited have been posited not only by professionals working with
families with children who have chronic illnesses or developmental
disabilities (Copley & Bodensteiner, 1987;Worthington, 1994)but
also by those who counsel the bereaved (Martin & Elder, 1993).
However, unlike these descriptive open-ended grief frameworks,
Volume 30, Number 2, Second Quarter 1998

the model of chronic SOITOW represents an alternative way of
viewing cyclical responses to loss experiences that is based on
extensive research.
Loss Situations
The primary antecedent event that must occur before the onset
of chronic sorrow is involvement in an experience of significant
loss. The loss may be ongoing with no predictable end, as with
the birth of a disabled child or diagnosis of a chronic illness, or it
may be a more circumscribed loss like the death of a loved one.
Since interpretation of loss is highly individualistic, it is difficult
to generalize about what may constitute a signifcant loss. What is
described as a significant loss by one person may not be viewed
the same by another. However, research has shown overwhelmingly
that the never-ending loss of a “perfect” child experienced by
parents of young children with physical or mental disabilitiesplaces
them at high risk for chronic sorrow (Burke, 1989; Damrosch &
Perry, 1989; Fraley, 1986; Golden, 1994; Hummel & Eastman,
1991; Mallow, 1994; Olshansky, 1962; Phillips, 1991; Seideman
& Kleine, 1995; Shumaker, 1995; Wikler et al., 1981).
Similarly, family caregivers of adult children, spouses, parents,
or other close relatives with physically or mentally debilitating
diseases confront losses associated with watching their loved
one’s condition deteriorate and experiencing the personal
sacrifices that accompany caregiving (Atkinson, 1994; Cockerill
& Warren, 1990; Miller, 1991; Miller, Dworkin, Ward, & Barone,
1990; Parks & Pilisuk, 1991). These experiences of ongoing loss
imbedded in the role of caregiver often lead to chronic sorrow
(Burke, Eakes, & Hainsworth, 1997; Eakes, 1995; Hainsworth,
1995; Hainsworth et al., 1995; Lindgren, 1996).
The presence of a chronic condition with its concomitant
uncertainty creates a situation for which there is no predictable
end (Loveys, 1990; Mishel, 1990). Moreover, both the actual and
symbolic losses associated with living with chronic illness or
disability are ongoing. Involvement in ongoing losses associated
with a chronic or life-threatening condition such as infertility,
cancer, or multiple sclerosis is likely to lead to the development
of chronic sorrow (Burke et al., 1997; Eakes, 1993; Eakes et al.,
1993; Hainsworth, 1994b; Hainsworth et al., 1993; Hainsworth
et al., 1994; Lindgren, 1996).
In contrast to ongoing loss experiences where there is no
predictable end to the loss-producing situation, death of a loved
one represents a circumscribed loss event that may precipitate
the development of chronic sorrow. Three consortium studies
conducted in 1994 investigated the occurrence of chronic sorrow
in individuals who had experienced the death of a family
member. These studies represent a landmark in exploring chronic
sorrow among those who have experienced circumscribed losses,
rather than ongoing losses. The sample consisted of 14 parents
who had experienced the death of a child, 10 people who had
lost a spouse through death, and 10 people who had experienced
the death of a family member following a long-term illness.
While the length of time since the death event ranged from 2 to
25 years, 97% of the sample showed chronic sorrow as identified
using the BurkelNCRCS Chronic Sorrow Questionnaire
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Chronic Sorrow Theory
(Bereaved Individual Version), a semi-structuredinterview guide.
The words of one man whose wife had died 10 years earlier provide
a portrait of the chronic sorrow associated with the death of a loved
one:
There are people that tell you that time will erase or time will change
things, but that’s not true. Time will make it easier, but time does not
erase what you have built up over many years. It doesn’t erase it so don’t
expect them (periodic grief-relatedfeelings)to go away. You can deal with
it as years pass, but I don’t think that I will ever, if I live to be 100, get
over it. My wife will always be a part of me. She left an impact on my
life and my child that nothing in this world will ever take away (Eakes,
1994).
While traditionally chronic sorrow has been associated only
with individuals involved in ongoing loss situations with no
predictable end, these latest findings about bereaved individuals
validate the experience of chronic sorrow not only for those
experiencing ongoing loss, but also for those who have
experienced a single loss. Therefore, we assume that any type
of significant loss experience may result in the development of
chronic SOKOW.
Disparity
A second key antecedent to chronic sorrow is unresolved
disparity resulting from the loss (Lindgren et al., 1993;Teel, 1991).
Disparity is created by loss experiences when the individual’s
current reality differs markedly from the idealized, when the loss
creates a gap between the desired relationship and the actual one.
Whether associated with ongoing loss as an affected individual or
caregiver or as a survivor of a single loss event, the existence of
ongoing, unresolved disparity is a common attribute of chronic
sorrow (Burke et al., 1997;Eakes, 1993; Eakes, 1995;Eakes et al.,
1993; Hainsworth, 199Ja; Hainsworth, 1995; Hainsworth et al.,
1993; Hainsworth et al., 1994; Hainsworth et al., 1995; Lindgren
et al., 1993;Teel, 1991). The unresolved disparity that characterizes
chronic sorrow may be equated with experiencing loss in bits and
pieces. The lack of closure of the gap created by the loss event sets
the stage for grief to be experienced periodically as reflected in the
comments of a mother whose child had died:
It’s a continual process and people who say it just ends after two years
... that after that you should be okay. Well that’s crazy. Time does change
you and you can adapt, but for me personally, it doesn’t completely heal
the scar that’s left (Burke, 1994).
Trigger Events
Within the theoretical framework of chronic sorrow, trigger
events are closely connected to the disparity.Triggers, also referred
to as milestones, are defined as those circumstances,situations, and
conditions that bring the negative disparity resulting from the loss
experience clearly into focus or that exacerbate the experience of
disparity (Burke et al., 1997; Eakes, 1995;Teel, 1991). Events that
are likely to trigger confrontation with ongoing disparity vary
dependingupon whether the loss is associatedwith having a chronic
or life-threatening condition, being a family caregiver, or
experiencingthe death of a loved one.
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Chronic Sorrow Theory
Affected Individuals
Chronic sorrow is most often triggered in individuals with
chronic or life-threatening conditions when the individual
experiences disparity with accepted norms. These norms may be
social, developmental , or personal (Burke et al., 1997; Eakes,
1993; Eakes et al., 1993; Hainsworth, 1994b). Individuals with
chronic or life-threateningillnesses may be stigmatized by society.
Moreover, their abilities to fully participate in and meet the
expectations of society may be compromised (Lubkin, 1990). An
example of disparity with social norms is the individualconfronting
the realization that he or she is “different” from others.
Developmental norms refer to those predictable, anticipated
milestones of individual or family development. One example of
disparity with family developmental norms is an infertile woman
of child-bearing age. People diagnosed with progressively
degenerative conditions such as multiple sclerosis, experience
ongoing disparity with previously established personal norms
almost certainly precipitate the chronic sorrow experience. Such
a situation may arise when one can no longer participate in an
activity previously enjoyed.
In addition to disparity with norms, events associated with
management of the illness such as hospitalization may bring the
ongoing disparity into focus for those affected by a chronic or life-
threatening condition (Burke et al., 1997; Eakes, 1993; Eakes, et
al, 1993; Hainsworth, 1994b; Lindgren, 1996).
Family Caregivers
For parents caring for young children with physical or mental
infiities, confrontation with disparity between the idealized and
the actual is overwhelmingly associated with developmental
milestones (Burke, 1989; Clubb, 1991; Damrosch & Perry, 1989;
Fraley, 1986; Fraley, 1990; Golden, 1994; Hummel & Eastman,
1991; Mallow, 1994; Olshansky, 1962; Phillips, 1991; Seideman
& Kleine, 1995; Shumaker, 1995; Wikler et al., 1981). The
discrepancy noted between a child‘s performance and the parents’
expectations of “normal” development brings the disparity clearly
into focus.
For other family caregivers, chronic sorrow is most often
triggered by management crises associated with the family
member’s illness and by events that reinforce the unending nature
of their caregivingresponsibilities(Burke et al., 1997;Eakes, 1995;
Eakes et al., 1993; Hainsworth, 1995; Hainsworth et al., 1995;
Lindgren, 1996). The potential for comparisons of abnormal
conditions with norms to trigger chronic sorrow is also apparent
in family caregivers. Situations and circumstancesthat precipitate
awareness of disparities between self and others, especially in
regard to developmental expectations, relationships and abilities
are commonly cited in this regard (Burke, 1989;Burke et al., 1997;
Eakes, 1995; Fraley, 1986; Hainsworth, 1995; Hummel & Eastman,
1991; Olshansky, 1962; Wikler et al., 1981). As the husband of a
woman with multiple sclerosis noted, “I can’t stand seeing couples
walking around the mall or taking their grandchildren out because
I know that will never happen with us” (Hainsworth, 1995).
Bereaved Individuals
In bereavement situations, the disparity that triggers chronic
sorrow is not the presence of a person with a chronic condition.
182 Image:]ournal of Nursing Scholarship
Rather, it is the disparity from the ideal created by the absence of a
person who was central in the life of the bereaved. Stated another
way, for bereaved individuals, it is the presence of the absence that
triggers chronic sorrow. The chronic sorrow experiencefor bereaved
people is most frequently triggered by confrontation with disparity
associated with memories of a past reality, often associated with
anniversary events, and with recognized variances from social norms
(Burke, 1994; Eakes, 1994; Hainsworth, 1994a). Moreover, role
changes necessitated by the death of a “significant other” also serve
as reminders of the negative disparity between the past and the
present and may precipitate chronic sorrow.
Management Methods
Management methods refer both to the coping strategies used by
a person with chronic sorrow (internal) and to interventionsprovided
by professionals (external). Use of effective coping methods and
provision of appropriateinterventionscan assist those with chronic
sorrow to regain their emotional equilibrium and achieve an
increased level of comfort. Employment of effective management
methods may also extend the period between trigger events and
reduce the degree of perceived disparity.
Effective Internal Management Methods
Individuals draw on a variety of strategies to cope with the
periodic re-grief associated with chronic sorrow. Positive personal
coping styles used by those with chronic sorrow are consistent
among affected individuals, family caregivers, and bereaved
individual and are congruous with styles identified in established
theories on stress and coping (Lazarus & Folkman, 1984).
Individuals most frequently cope positively with chronic sorrow by
using action strategies designed to help them feel more in control
of their lives (Burke, 1989; Eakes, 1993; Eakes, 1995; Hainsworth
et al., 1994; Hainsworth, 1995; Hainsworth et al., 1995; Lindgren,
1996). These strategies include maintaining involvement in personal
interests and activities, pursuing respite opportunities, and seeking
information related to one’s loss experience. Cognitive methods of
coping are also frequently used to manage the feelings associated
with chronic sorrow (Burke, 1989; Eakes, 1993; Eakes,1995;
Hainsworth et al., 1994; Hainsworth, 1995; Hainsworth et al., 1995).
These strategies involve having a “can do” attitude, taking one day
at a time, and concentratingon the positive aspects of one’s life.
Another category of strategies for coping with chronic sorrow is
the interpersonal (Burke, 1989; Eakes, 1993; Eakes, 1995; Fraley,
1990; Hainsworth et al. 1994; Hainsworth, 1995; Hainsworth et al.,
1995; Wikler et al., 1981). These strategies include talking with
others involved in the same or a similar loss situation, talking with
someone close, or talking with a trusted professional.Other positive
coping styles that are sometimes described, although less frequently,
are emotional (e.g., having a good cry) and spiritual (e.g., relying
on religious or personal beliefs and practices for comfort).
Effective External Management Methods
It is important to note that management methods provided by
health care professionals should be based on a conceptualization
of chronic sorrow as normal rather than pathological. Normalization
Volume 30, Number 2, Second Quarter 1998

of the experience is, in and of itself, the foundation upon which
other interventions are built. Nurses and other providers should
recognize that individuals who have been diagnosed with chronic
or life-threatening conditions, parents of young children with
disabilities, caregivers for ill or disabled relatives, and individuals
bereaved through the death of loved ones may experience the
periodic recurrence of grief-related feelings defined as chronic
sorrow. Awareness of the circumstances and situations that are
likely to trigger chronic sorrow allows for provision of anticipatory
guidance. Personal coping styles can be assessed by simply asking,
“What helps?’ Once identified, positive coping strategies should
be strengthenedand supported. For those lacking effective coping
abilities, strategies identified as effective in dealing with chronic
sorrow can be taught.
Further, specific actions by health care professionals have been
identified as helpful in reducing the emotional pain of chronic
sorrow. These interventionscan be categorized as roles that nurses
and other health care providers can assume in their contacts with
individuals experiencing chronic SOITOW (Burke, 1989; Copley &
Bodensteiner, 1987; Eakes, 1993; Eakes, 1995; Eakes et al. 1993;
Fraley, 1990; Hainsworth, 1995; Hainsworth et al., 1995; Hummel
& Eastman, 1991;Wikler et al., 1981).
For people diagnosed with chronic or life-threatening illnesses,
as well as bereaved individuals, interventions demonstrative of an
empathetic presence and a caring professional are most helpful
(Burke, 1989; Eakes, 1993; Eakes et al., 1993; Hainsworth et al.,
1995). The interventions that typlfy the role of empatheticpresence
include taking time to listen, offering support and reassurance,
recognizing and focusing on feelings, and appreciating the
uniqueness of each individual and family. The complementary role
of caring professional is exemplifiedby being sensitive, respectful,
non-judgmental, tactful, patient, and compassionate in contacts
with those experiencing c h n i c sorrow. Also beneficial to affected
individuals are interventions reflective of the teacher and expert
role highlighted below.
Parents of young children with disabilities and other family
caregivers receive the most benefit from interventions associated
with the role of teachedexpert (Burke, 1989; Clubb, 1991;Eakes,
1995; Fraley, 1990; Hainsworth, 1995; Hainsworth et al., 1995;
Hummel & Eastman, 1991; Warda, 1992; Wikler et al., 1981),
including provision of accurate, situation-specific information in
a manner that can be both heard and understood, and practical tips
for dealing with the challengesof caregiving. Empathetic presence,
as described above, also assists these caregivers to cope with the
experience of chronic sorrow (Burke, 1989; Clubb, 1991; Eakes,
1995; Fraley, 1990; Hainsworth, 1995;Hummel & Eastman, 1991;
Olshansky, 1962; Phillips, 1991; Teel, 1991; Warda, 1992).
Summary and Conclusions
Our middle-range theory of chronic sorrow provides a
framework for understanding the reactions of individuals to loss.
This theory has been derived from interviews with 196 individuals,
from young adults to the elderly, who have shared their experiences
as people with chronic conditions, family caregivers of the
chronically ill, or as bereaved family members. Whatever the
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Chronic Sorrow Theory
nature of the loss situation, if ongoing disparity is created, chronic
sorrow is likely to be experienced. Indeed, a total of 169 (86%) of
those studied showed evidence of chronic sorrow.
Nurses and other health care professionals should recognize that
chronic sorrow is commonly experiencedby individuals across the
lifespan who have encountered significant loss or experience
ongoing loss. Further, it is important that they view the recurring
periodic episodes of sadness and other emotions characteristic of
grief as a normal response to the ongoing disparity created by the
loss and provide needed support when chronic sorrow is triggered.
There are numerous implications suggested by this study for
research on the theory of chronic sorrow. First and foremost, a
concise instrument to i d e n m the presence of chronic sorrow must
be developed to facilitate future research and guide practice-related
assessment and intervention. Second, further study is needed to test
the theory and its generalizability to populations and loss situations
not yet studied. More specifically, its relevance for various cultural
groups should be explored. Along with empirical testing of the
theory of chronic sorrow, intervention studies focused on the
identificationof strategies to reduce disparity created by loss should
be conducted. Strategies already described in the chronic illness and
grief literature, such as individual counseling and support groups,
should be tested for their effectiveness in reducing the disparity
associated with chronic sorrow. Such additional study will be useful
in determining if ongoing disparity can be substantiallyreduced and
chronic sorrow can be alleviated in those who experience this
phenomenon. ~ E
FJ
References
Atkinson, S.D. (1994). Grieving and loss in parents with a schizophrenic child.
American Journal of Psychiatry, 151, 1137-1139.
Bowlby, J. (1980). Attachment and loss: Vo1.m: Loss,sadness and depresion.
New York: Basic Books.
Burke, M.L. (1989). Chronic sorrow in mothers of school-age children with a
myelomeningocele disability (Doctoral Dissertation, Boston University, 1989).
Dissertation Abstracts International, 50,233-234B.
Burke, M.L. (1992). [An investigation of chronic sorrow in infertile couples].
Unpublished raw data.
Burke, M.L. (1994). [An investigation of chronic sorrow in bereaved parents].
Unpublished raw data.
Burke, M.L., Eakes, G.G., & Hainsworth, M.A. (1997). Milestones of chronic
sorrow:Perspectivesof affectedindividualsand family caregivers.Manuscript
submitted for publication.
Burke,M.L.,Hainsworth,M.A.,Eakes,G.G., & Lindgren, C.L. (1992). Current
knowledge and research on chronic sorrow: A foundation for inquiry. Death
Studies, 16,231-245.
Clubb, RL. (199 1). Chronic sorrow: Adaptation patterns of parents with chronically
ill children. Pediatric nursing, 17,462-466.
Cockerill, R , & Warren, S. (1990). Care for caregivers: The needs of family
members of MS patients. Journal of Rehabilitation, 1 , 4 1 4 .
Copley, M.F., & Bodensteiner,J.B. (1987). Chronic sorrow in families of disabled
children. Journal of Child Neurology, 2,67-70.
Dammsch, S.P., & Perry, LA. (1989). Self-repottedadjustment, chronic sonow, and
coping of parents of children with Down syndrome. Nursing Rgeardq 38,25-30.
Davis, B.H. (1987). Disability and grief. Social Casework, 68,352-357.
Eakes, G.G. (1993). Chronic sorrow: A response to living with cancer. Oncology
Nursing FOW, 20,1327-1334.
Eakes, G.G. (1994). [An investigation of chronic sorrow among bereaved
individuals]. Unpublished raw data.
Eakes, G.G. (1995). Chronic sorrow: The lived experience of parents of chronically
mentally ill individuals. Archives of Psychiatric Nursing, M,77-84.
Eakes,G.G.,Burke,M.L.,Hainsworth,M.E.,& Lindgren, C.L. (1993). Chronic
sorrow: An examination of nursing roles. In S.G. Funk, E M . Tornquist, M.T.
Champagne, & R.A. Wiese (Eds.), Key aspects of caringfor the Chronically ill:
Hospital and home (231-236). New York Springer.
183
Chronic Sorrow Theory
Eakes, G.G., Hainsworth, M.E., Lindgren, C.L., & Burke, M.L. (1991).
Establishing a long-distance research consortium. Nursing Connedions,4,5 1-57.
Fraley, A.M. (1986). Chronic sorrow in parents of premature children. Children’s
Health Care, 15, 114-118.
Fraley, A.M. (1990). Chronic sorrow: A parental response. Journal of Pediatric
Nursing, 5,268-273.
Golden, 8 . (1994). The presenceof chronic sorrow in mothers of children with
cerebral palsy. Unpublishedmaster’s thesis, Arizona State University, Tempe.
Hainsworth, M.A. (1994a). [An investigation of chronic sorrow in bereaved
spouses]. Unpublished raw data.
Hainsworth, M.A. (1994b). Living with multiple sclerosis: The experience of
chronic sorrow. Journal of NeuroscienceNursing, 26,237-240.
Hainsworth, M.A. (1995).Chronic sorrow in spousecaregiversof individualswith
multiple sclerosis:A case study. Journal of GerontologicalNursing, 21, 29-
33.
Hainsworth,M.A.,Burke,M.L.,Lindgren,C.L.,&Eakes,G.G.(1993). Chronic
sorrow in multiple sclerosis:A case study. Home HealthcareNurse, 11,9-13.
Hainsworth, M.A., Busch, P.V., Eakes, G.G., & Burke, M.L. (1995). Chronic
sorrow in women with chronically mentally disabled husbands. Journal of the
American PsychiatricAssociation, 1(4), 120-124.
Hainsworth, M.A., Eakes, G.G., & Burke, M.L. (1994). Coping with chronic
sorrow. Issues in Mental Health Nursing, 15,59-66.
Hummel, P.A., & Eastman, D.L. (1991). Do parents of premature infants suffer
chronic sorrow? Neonatal Network, 10,59-65.
Lazarus, R.S., & Folkman, S. (1 984). Stress, appraisal, and coping. New York
Springer.
Lindemann,E. (1944). Symptomatologyand managementof acute grief. American
Journal of Psychiatry,101, 141-148.
Lindgren, C.L. (1996). Chronic sorrow in persons with Parkinson’s and their
spouses. ScholarlyInquiry for Nursing Practice, 10,351-367.
Lmdgren, C.L., Burke, M.L., Hainsworth,MA., & Eakes,G.G. (1992). Chronic
sorrow:A lifespan concept. ScholarlyInquiry for Nursing Practice, 6 , 2 7 4 .
Loveys, B. (1990).Transitionsin chronicillness: The at-risk role. Holistic Nursing
Practice, 4,5644.
Lubkin, I.M. (1990). Chronic illness: Impact and interventions.Boston: Jones
& Bartlett.
Mallow, G. (1 994). A comparisonof the lived experience of chronic sorrow by
mothers and fathers of chronidy iI1 childmn. Unpublished master’s thesis,
University of South Dakota.
Martin,K., & Elder, S. (1993).Pathwaysthrough grief: Amodel of the process. In
J.D. Morgan (Ed.), Personal care in an impersonal world A multidimensional
look at bereavement(73-86).Amityville, NY Baywood.
Miller, B. (1991).Elderly married couples, gender, and caregiver strain. Advances
in Medical Sociology,2,245-266.
Miller, F., Dworkin, J., Ward, M., & Barone, D. (1990). A preliminary study of
unresolved grief in families of seriously mentally ill patients. Hospital and
Community Psychiatry,41,1321-1325.
Mishel, M.H. (1990). Reconceptualization of the uncertainty in illness theory.
Image: Journal of Nursing Scholarship,22,256-262.
Olshansky, S. (1962). Chronic sorrow: Aresponse to having a mentally defective
child. Social Casework,43,191-193.
Parks, S.H., & Pilisuk, M. (1991).Caregiverburden: Gender and the psychological
costs of caregiving.American Journal of Orthopsychiatry,6,501-509.
Phillips, M. (1991). Chronic sorrow in mothers of chronically ill and disabled
children. Issues in ComprehensivePediatric Nursing, 14, 111-120.
Quint, J.C. (1969). Some thoughts on a theory of chronicity. In C.M.Noms (Eds.),
Proceedingsof the first nursing theory conference(58-67). Kansas City, KS:
University of Kansas Medical Center, Department of Nursing Education.
Seideman, R.Y., & Kleine, P.F. (1995). A theory of transformed parenting:
Parenting a child with developmental delayhental retardation. Nursing
Research, 4 4 , 3 8 4 .
Shumaker, D. (1995). Chronic sorrow in mothers of children with cystic
fibrosis. Unpublished master’s thesis, University of Tennessee, Memphis.
Stephenson,J.S., & Murphy, D. (1986). Existential grief The special case of
the chronically ill and disabled. Death Studies, 10, 135-145.
Teel, C.S. (1991). Chronic sorrow:Analysis of the concept. Journal of Advanced
Nursing, 16, 1322.1319.
Walker, L.O., & Avant, K.C. (1995). Strategies for theory construction in
nursing. (3rd ed.) Norwalk, CT: Appleton & Lange.
Warda, M. (1992).The family and chronic sorrow: Role theory approach.Journal
of Pediatric Nursing, 7,205-210.
184 /mage:/ournal of Nursing Scholarship
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ChcalSidebar by Susan R. Reddin!
The teen-aged hospice patient and her family when her cancer goes into
remission but leaves her blind
The 54-year-old man who suffers severe head injuries on the way to his
wedding
The feelings of loss expressed by the 28-year-old infertile woman as she
cares for her slowly dying father
The 78 year old who finally shares her feelings associatedwith her loss of
four babies prenatally-
Each of these exhibit disparity in response to loss and had symptoms of
chronic sorrow, as described by Eakes and colleagues. This middle-range theory
of chronic sorrow has wide application for nurses in clinical practice.
Nurses in all practice settings can benefit from knowledge of trigger events
as well as internal and external management methods of coping with chronic
sorrow. This knowledge can benefit nurses in their professionalpractice and in
their personal lives. No one who lives is exempt from loss and, consequently,
from the potential for chronic sorrow.
Nurses in acute-care and long-term care settings can anticipate symptoms
associated with chronic sorrow, in both patients and caregivers when people with
chronic diseases require hospitalization or slowly lose abilities to perform
activities of daily living. “Wellness-illnessis a human experience of actual or
perceived function-dysfunction through the interaction of cognitive-affective
dimensions.” Jensen and Men’s study (Dossey, Keegan, Guzztta, & Kolkmeier,
1995). Given the fact that patients may have physical manifestations of
psychological, emotional, or spiritual problems-nurses should be alert to
triggers of chronic sorrow and incorporateappropriateresponses in assessments
of those at-risk.
Hospice programs typically provide support to loved ones of the dying and
deceased and offer anticipatory counseling.Sorrow, however, is not time-limited
and may be present, in some manner as long as memory is intact and, perhaps
longer. One 80-year-old woman with advanced dementia sometimes awakened
sobbing uncontrollably about the events associated with her mother’s “recent”
death.
Nurses should make provision for bereavement counseling when events
trigger symptoms of chronic sorrow that can occur years after the loss. They
should proved for anticipatorycounseling for trigger events as well as reinforce
effective internal and external coping mechanisms.
The emphasis on normalization of the experience of chronic sorrow as the
foundation for intervention deserves emphasis. Feelings have a function and
should be respected as integral to the process of meaning reconstruction,rather
than controlledor eliminated as unwanted by-products of loss (Neimeyer, 1993).
Nurses in hospice programs have long realized that meaningful and
appropriateinvolvementof caregiversin meeting the needs of their dying loved
ones contributes to more healthful grieving. Indeed, hospice nurses can
contribute to research on the theory of chronic sorrow by identifying ways to
reduce disparity created by loss.
Kubler-Ross, among others, has given us models for dealing with loss.
However, “Because you loved, grief continuesto walk by your side” (Grollman,
1997, p.154). The theory described by Eakes, Burke, and Hainsworth can help
us develop models of intervention for those suffering chronic sorrow.
References
Dossey,BM., Keegan, L., Guzzetta, C.E., & Kolkmeier,L.G. (1995) Holistic
nursing practice. Gaithersburg, MD: Aspen.
Growan, E.A. (1997). A decalogue: Ten commandments for the concerned
caregiver. In K.J.Doka & J.Davidson (Eds.). Living with grief when illness
is prolonged (149-58). Bristol, PA: Taylor & Francis.
Neimeyer, R.A. (1993). Constructivism and the cognitive psychotherapies:
Some conceptual and strategic contrasts. Journal of Cognitive
Psychotherapy, 7, 159-71.
Wikler, L.M., Wasow, M., & Hatfleld,E. (1981). Chronic sorrow revisited:Parents
vs. professional depiction of the adjustment of parents of mentally retarded
children. AmericanJournal of Orthopsychiatry,51,63-70.
Worthington, R.C. (1994, May). Models of linear and cyclical grief: Different
approachesto different experiences. Clinical Pediatrics,297-300.
Volume 30, Number 2, Second Quarter 1998