After Diagnosis Family Caregiving with Hospice Patients

Visit the link below to download the full version of this book:

https://medipdf.com/product/after-diagnosis-family-caregiving-with-hospice-patie
nts/

Click Download Now

John G. Bruhn
Department of Sociology
Northern Arizona University
Flagstaff, AZ
USA

ISSN 2211-7644 ISSN 2211-7652 (electronic)

SpringerBriefs in Well-Being and Quality of Life Research
ISBN 978-3-319-29801-6 ISBN 978-3-319-29803-0 (eBook)
DOI 10.1007/978-3-319-29803-0

Library of Congress Control Number: 2016931842

© The Author(s) 2016

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, express or implied, with respect to the material contained herein or
for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by SpringerNature

The registered company is Springer International Publishing AG Switzerland
To the hospice patients
who inspire others to live
hopefully and to die courageously
Old friends pass away, new friends appear. It is just like
the days.
An old day passes, a new day arrives.
The important thing is to make it meaningful:
a meaningful friend – or a meaningful day.

—Dalai Lama

There is a light in this world, a healing spirit more

powerful than any darkness we may encounter. We
sometimes lose sight of this force when there is suffering,
and too much pain. Then suddenly, the spirit will emerge
through the lives of ordinary people who hear a call and
answer in extraordinary ways.

—Mother Teresa
Acknowledgments

Hospice provided me with the opportunity to participate as a volunteer respite

caregiver over the past 10 years. Periodic workshops and peer-group gatherings
enabled volunteers to share experiences, gain support from each other, and become
advocates for hospice as an excellent option for terminal care.
Tracy Grindle typed numerous drafts of this book and provided valued sug-
gestions. Vince Colburn contributed his excellent skills in graphic art.

ix
A Note to Readers

All of the patient examples and narratives are real, but details regarding demo-
graphics and social and psychological factors have been altered to protect patient
privacy and identity. The patients were assigned to me for respite care until they
passed. I did not interview patients or use a standard questionnaire or a recording
device. My data was primarily based on my observation and interaction with family
members. This is a book of reflective learning and is not intended to be a formal,
scientific study. I was “with” patients for an average of two to four hours weekly for
about six months. My role was as a respite volunteer who enabled the caregiver to
experience unstructured time (respite).

xi
Contents

1 Who are Caregivers? . .......... . . . . . . . . . . . . . . . . . . . . . . . . 1

Becoming a Caregiver . .......... . . . . . . . . . . . . . . . . . . . . . . . . 3
Caregiving: A Dynamic Relationship . . . . . . . . . . . . . . . . . . . . . . . . . 4
References . . . . . . . . . .......... . . . . . . . . . . . . . . . . . . . . . . . . 6
2 Time as a Concept in Caregiving . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Limits of Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Fitting Living into Dying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3 The Emotional Roller Coaster of Caregiving . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4 Dying Is a Team Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
5 Spirit: The Timekeeper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dying More Than Once . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Time: The Great Equalizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6 Holding on and Giving Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
The Family—A Healing System. . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
After the Angels Have Left . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Lingering Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Multiple Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7 Healing Behavior for Caregivers. . . . . . . . . . . . . . . . . . . . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
8 Vignettes of Family Caregiving. . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Whatto Do About Aunt Mary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Good Transitions for a Determined Dad . . . . . . . . . . . . . . . . . . . . . . . 46

xiii
xiv Contents

Being Present Was Enough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Separate yet Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Do You Love Me? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
9 Renewal and Remembrances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Memories with Smiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Introduction

The image some people have of dying is a hopeless, helpless, lonely, and often
painful ordeal that creates a financial, emotional, and caregiving burden on the
family (Leary 2012). Other people, with the help of guided imagery, have a less
threatening view of dying and death (Staudt and Ellens 2013). It seems that we all
hope for “a good death”—sudden, painless, and with no or limited imposition on
others.
In reality, dying is a lifelong process that begins with birth (Kastenbaum 2002).
Dying is a part of living. We have choices in how we want to live life and, to some
extent, how we want to die. Our attitudes toward living also influence our attitudes
towards death. It is not unexpected that as we age we will have to live with the
consequences of a disabling chronic disease. Some diseases impose significant
limitations in how we can live life, others have minimal limitations. We can’t select
our diseases, they pick us, but we can choose how we live and die with them.
Ultimately we all die from the same cause—our hearts stop. It is what is in our
hearts that make us different, and how we connect with the hearts of others that
determines our legacy.
The process of dying is unique to each individual and family. At one extreme,
individuals share few, if any, of their thoughts and feelings about dying. At the
other extreme, individuals wish to complete unfinished business and plan their own
funerals. Between those extremes, people express a variety of feelings as their
physical and mental conditions change. Families and friends may help or hinder the
dying process with their own agendas. The dying process is often difficult for the
survivors as they waver about what to do, or not to do, in their projections of what
they think should be “a good death” for the family member. Hospice professionals
and volunteers frequently become involved as facilitators and mediators in helping
patients and their families to confront realities and meet changing needs in their
final times.
Hospice service causes a person to prioritize their values. Hospice services can
be uplifting if it leads us to make new friends and learn from patients and their

xv
xvi Introduction

families about how they have lived their lives. Talk about life, past, present, and
future, and death, if they bring up the topic, can provide insights into family
resilience. My life has been enriched by hearing about the experiences of others, the
choices they made, and things they valued, the satisfactions they enjoyed, the
challenges they conquered, and the legacies they plan to leave. And how they lived
was usually reflected in how they faced death.
We often wait until the end of life to reflect on what is important in life. Then it’s
too late to do anything about regrets or to spend more time doing what is important
to us. Too often we don’t stop and take stock of where we are, what we have done,
and what we want to accomplish. We are too busy trying to conquer our enemy—
time. In the end, time is a friend to those who have valued and used it as the gift that
it is.
The purpose of this book is to better understand the role of caregiver and its
many dimensions and complexities. The best way to learn about caregiving is to
experience its ups and downs and share them so burn-out can be prevented. Since
death is the ultimate experience for all of us, it is beneficial to understand care at the
end of life better. This book is about what I have learned as a respite volunteer by
observing and sharing time with 40 hospice patients and their caregivers at different
points in their journeys with time. For some patients, time was an enemy, for others
it was a friend, and for still others, time was not important. Our legacy is the story
of how we used our time, which is the final gift we share with others.
Families are known to be emotional anchors and to show resilience when
problems or crises threaten one of its members. For a family to be told that one of
its members has six months or less to live can be devastating. What happens to one
family member affects the stability of the family system. Families tend to react to
the news of a terminal illness much like they have reacted to other crises. A terminal
illness can bring families together or it can tear them apart (Cohen 2008). The
reactions of families and their members change as the sick member’s illness
changes. The needs of the ill person may exceed a family’s ability to be sole
caregivers. Professional caregivers may be needed in lieu of, or in addition to,
family caregivers.
Hospice is not an easy choice for a person and their family to make. Patients and
their families may understand that they have a fatal illness but not necessarily that
they are dying (Gawande 2014).
The grief process begins when the family learns that a member has a terminal
illness. The psychodynamics of the family changes as the primary caregiver is
identified; other members of the family may need to change their priorities, roles
and responsibilities, and the family and/or its representative decides whether or not
they need the additional assistance of professional caregivers. One of the early steps
in the grief process is identifying the extent of personal, financial, and other
resources needed to help with caretaking (Okun and Nowinski 2011). Families
begin to activate their support systems involving extended family, friends, and
hospice. Family composition, time demands, and economic constraints will
Introduction xvii

determine the most supportive environment for the patient. A terminal patient may
be more comfortable at home under hospice care. An end-of-life prognosis activates
different feelings and expectations among family members, especially if the family
is geographically dispersed and not closely networked. As a plan is developed to
provide caregiving to the family member, the stress of the situation may precipitate
feelings of guilt, anger, and family member rivalry. A terminal illness can be a test
of family cohesiveness and its long-term stability. The nature of the illness, the
amount and type of care needed, the age of the patient, and their values and beliefs
all help to shape a personal care plan for the patient.
Sixty-one percent of patients die in hospitals or other acute treatment facilities
where extending the length of life is the major objective. Hospice is still a concept
and approach that is new to health professionals and laymen. Therefore, patients
who enter hospice care do so late in the course of their terminal illnesses (Connor
et al. 2007). The U.S. culture still defers to families as the primary caregivers for
terminally ill and dying family members. Hospice care can provide a supportive
noninvasive environment linked with a philosophy of managing pain and suffering
(Carlson et al. 2010; Han et al. 2006; Talley and Crews 2007). Hospice care offers
several advantages over traditional hospital-based care for people with terminal
illnesses. It can be delivered in a patient’s home, allowing death to take place at
home, or may optimize the relief of pain, increase patients’ satisfaction, and
increase cost-effectiveness (Christakis and Escarce 1996).

References

Carlson, M. D. A., Bradley, E. H., Du, Q., & Morrison, R. S. (2010). Geographic access to hospice
in the United States. Journal of Palliative Medicine, 13(11), 1331–1338.
Christakis, N. A., & Escarce, J. J. (1996). Survival of medicare patients after enrollment in hospice
programs. New England Journal of Medicine, 335(3), 172–178.
Cohen, R. M. (2008). Strong at the broken places. New York: Harper Collins Publishers.
Connor, S. R., Pyenson, B., Fitch, K., & Spence, C. (2007). Comparing hospice and non-hospice
patient survival among patients who die within a three-year window. Journal of Pain and
Symptom Management, 33(3), 238–246.
Gawande, A. (2014). Being mortal. New York: Metropolitan Books.
Han, B., Remsburg, R. E., McAuley, M. J., Keay, T. J., & Travis, S. S. (2006). National trends in
adult hospice use: 1991–1992 to 1999–2000, Health Affairs, 25(3), 792–799.
Kastenbaum, R. (Ed.). (2002). Macmillan encyclopedia of death and dying (Vol. 1, 2). New York,
USA: Macmillan Reference.
Leary, L. (2012, April 12). No one has to die alone. Psychology Today.
Okun, B., & Nowinski, J. (2011). Saying goodbye: How families can find renewal through loss.
New York: Berkeley Books, Penguin Group (Copyright by Harvard University).
Staudt, C., & Ellens, J. H. (Eds.). (2013). Our changing journey to the end: Death, dying, and grief
in America (Vol. 1). Santa Barbara, CA: Praeger.
Talley, R. C., & Crews, J. E. (2007). Framing the public health of caregiving. American Journal of
Public Health, 97(2), 224–228.
Chapter 1
Who are Caregivers?

Abstract Caregivers are present in some form in all societies. An estimated 65.7
million caregivers make up 29 % of the U.S. population providing care to someone
who is ill, disabled, or aged. Caregiving is not a simple matter. It is a complex role
usually added to other roles a person has in a family. Caregiving can become a long
standing and stressful commitment if the family member has a chronic illness. Care‐
giving is a relationship that is continually changing. Hospice care requires flexible
caregiving. In many instances a mix of professional and family caregivers provides
care to patients, each contributing their skills, knowledge and support to the patient.

Keywords Becoming a caregiver · Caregivers (defined) · New population of

caregivers · Relationships in caregiving

Caregivers are present in some form in all societies. A caregiver is someone who
assumes responsibility for the care of an individual who has poor mental health, is
physically disabled, or whose health is impaired by sickness or old age. The term
“caregiver” may be prefixed with family, spouse, child, parent to distinguish between
different care situations and whether the caregiver is a professional or a volunteer.
Informal caregivers such as friends, neighbors or family members are unpaid and
assist with activities of daily living and tasks in a patient’s home. Formal caregivers
are paid for providing care at home or in a care setting such as daycare in a residential
setting. An estimated 65.7 million caregivers make up 29 % of the U.S. adult popu‐
lation providing care to someone who is ill, disabled, or aged (National Alliance for
Caregiving and AARP 2009).
More women than men are caregivers; an estimated 66 % of caregivers are female
(Suthers 2006). One-third (34 %) take care of two or more people. The average age
of a female caregiver is 48 years (National Alliance for Caregiving and AARP
2009). Men are sharing in caregiving tasks more than in the past, but women still
shoulder the major burden of care. Many caregivers of older people are growing
older themselves—the average age is 63 years (Marks et al. 2002).
A new population of caregivers to the elderly are children and grandchildren aged
40 and younger. Adults who act as caregivers for both their parents and children are

© The Author(s) 2016 1

J.G. Bruhn, After Diagnosis: Family Caregiving with Hospice Patients,
SpringerBriefs in Well-Being and Quality of Life Research,
DOI 10.1007/978-3-319-29803-0_1
2 1 Who are Caregivers?

called the Sandwich Generation. These young adults provide care for their aging
parents while supporting their own children (Spillman and Pezzin 2000).
Nearly 80 % of all long-term care is now provided at home by family caregivers
to children and adults with serious conditions, including mental illness. Family
members who are caregivers provide the foundation for long-term care in the U.S.
(Abutaleb 2013; George 1993).
If family caregivers were no longer available, the economic costs to U.S. health‐
care and long-term services would increase astronomically. In 2009, about 42.1
million family caregivers in the U.S. provided care to an adult with limitations in
daily activities at any given point in time, and about 61.6 million provided care at
some time during the year. The estimated economic value of their unpaid contribu‐
tions was about $450 billion (Family Caregiver Alliance, National Center on Care‐
giving 2012).
The National Center on Caregiving and AARP (2004) conducted a national
survey of 6,139 adults in the U.S. from which 1,247 caregivers were identified in
2003. A profile of caregiving was identified. Caregivers fill multiple roles with the
majority (83 %) of caregivers helping family members. The typical caregiver is a
46 year-old woman who has at least some college experience and provides more than
20 h of care each week. Nearly eight in ten care recipients is age 50 or older. More
than half (55 %) of care recipients live in their own homes.
Most caregivers say they experience little physical strain (67 %), no emotional
stress (44 %) and no financial hardship (77 %). However, caregivers say they provide
Level 1 Burden of Care. Analysis showed that the greatest predictors of physical
strain are the caregivers own health and whether they feel they had a choice in taking
on caretaking responsibilities. Caregivers who report poorer health and those that
feel they did not have a choice in taking on the role of caretaker experienced the
greatest physical strain. The Level of Burden ranges from Level 1 minimal care to
Level 5 maximum care, which contributes to caretaker’s physical strain. The greatest
influences on caregivers’ emotional stress is their Level of Burden, not feeling they
had a choice in taking on the role of caregiver, and living in the same household as
the person they care for. Almost half of Level 5 caregivers say they need help
managing their stress (49 %) and finding time for themselves (53 %).
Wheaton (1990) points out that major life changes and role transitions are often
treated as stressors that create a generalized demand for adjustment by an indi‐
vidual. However, transitions have been shown to produce a wide range of effects.
Rather than assume that life transitions are inherently stressful, it is useful to
determine the social circumstances surrounding “role changes” that influence
whether or not a role change or transition is stressful or not. The potential for the
impact of a life transition to be stressful is determined by the individual’s accu‐
mulated experience in the role that is altered by the transition—what can be
termed the “role history” prior to the event.
Becoming a Caregiver 3

Becoming a Caregiver

Most family caregivers are motivated to assume this role out of love and devotion
for the care recipient (Sheehy 2011). But becoming a caregiver is not a simple matter.
Caregiving is a complex role usually added to the other roles a person has in a family,
such as the role of breadwinner, parent or husband. Caregiving can become a long
standing and stressful commitment if the family member has a chronic illness.
Sometimes the caregiver role is assumed somewhat reluctantly if there are no
other living relatives who agree to take on this role, especially when the family
member’s condition worsens and caregiving becomes more demanding.
The caregiver role grows larger in scope and responsibility as the patient’s illness
changes, especially as the patient becomes more dependent on others for help in
performing the tasks of daily life. More people to assist in caregiving will be needed
for longer periods of time. Options for help within the family may be limited because
of job and personal responsibility in their own lives and limited finances may make
it impossible to consider a group home or other environment. The caregiver role can
be a source of stress (Scott 2014). Table 1.1 offers some questions and issues for
persons considering the caregiver role.

Table 1.1 Some questions

1. What is the nature of the patient’s illness? What are the
and issues a family member
patient’s care needs now and how are these projected to change?
needs to consider before
Where is the patient currently residing and what are the current
agreeing to be a caregiver
sources of support (physical, fiscal, social-emotional) for the
patient? What are the patient’s and family’s expectations
regarding the patient’s total care including end-of-life care?
2. What are the limitations of the primary caregiver’s ability and
qualifications in providing care? If, and when, should
professional caregivers become involved in the patient’s care?
Who are secondary caregivers and resources that could be called
upon when needed?
3. Create a care plan for the patient and review and update it
daily/weekly
4. What are the family’s support resources (financial, respite)
available to the primary caregiver? How does the caregiver cope
with stress and dying patients? The plan should include respite
for the caregiver and professional intervention for the caregiver
if needed
5. Caregivers should maintain open communication between
themselves, the rest of the family and all involved in the patient’s
care
6. Caregivers should monitor any changes in the family’s attitude
about end-of-life care regarding resuscitations and pain
management
7. List and compare the burdens (costs) versus the rewards
(gains) to becoming a caregiver
4 1 Who are Caregivers?

The role of caregiver can become increasingly burdensome if the person needing
care is permanently disabled and dependent upon others. Indeed, if the patient needs
constant supervision for safety concerns, caregiving may involve the entire family.
The extent of resources needed such as 24-h care may depend upon the degree to
which the family member’s illness is debilitating. For example, a family member
may suffer a stroke which severely limits his mobility and, in addition, he is diag‐
nosed with Parkinson’s disease affecting his movements. For safety reasons he
cannot be left alone. Despite his wife’s availability as his primary caretaker, and the
assistance of hospice professionals and volunteers, he is confined to bed. He has
become totally dependent on others; as time has gone on he is now fully bedfast.
Limited finances have necessitated the need for home care. His common moods are
frustration and anger, and the need for more morphine to manage his aggression and
pain. Caregiving has required the involvement of his wife, two hospice nurses, two
sons and two volunteers.
Caregivers are needed especially at the end of life. They are essential because
they provide needed help with activities of daily living, medications, eating, trans‐
portation, emotional support and communicating with health care professionals
about the patient’s condition. Although there are personal rewards involved for the
caregiver, serving as a caregiver over a period of time can be stressful, negatively
affecting many aspects of the quality of their own lives (McMillan 2005; Bruhn and
Rebach 2014).

Caregiving: A Dynamic Relationship

Caregiving is a relationship that is continually changing; caregivers’ initial commit‐

ments often need modification as the needs of the patient change. Some patients may
only need hospice services for a few days, or weeks, or months, while others exceed
their medical projected lifetime by several years. Hospice care requires flexible
caregiving, yet there are decision points that characterize most situations (see
Fig. 1.1).
The process of hospice caregiving begins with the diagnosis of a terminal illness
and an acceptance by the patient and their family that a cure is not possible for the
patient’s illness. Denial may be the first response to this news. Indeed, hope that the
condition can be abated or delayed is often a privately held opinion by the patient
and their family. Figure 1.1 indicates that a plan and place for care are the first
decisions to be made; a caregiver needs to be identified. The patient’s condition will
greatly influence the total plan of care and the availability of funds will prescribe the
options for where the care can be given (home, group home, nursing home, etc.).
The place of care may change as the patient’s condition and resources change.
Figure 1.1 points out the relationship between professional (formal) and family
(informal) caregivers. In many instances a mix of professional and family caregivers
provides care to patients, each contributing their skills, knowledge and support to
the patient. The grief process is also part of the total patient care plan including family
Caregiving: A Dynamic Relationship 5

Fig. 1.1 The dynamic relationships and decision points in caregiving to hospice patients
6 1 Who are Caregivers?

and professional caregivers. Most hospices provide bereavement services following

the death of the patient. Services include a variety of support groups, individual
counseling, telephone follow-up, and educational materials to help families and
caregivers engage in their own renewal.

References

Abutaleb, Y. (2013). Two-fifths of U.S. adults care for sick elderly relatives. Reuters, June 20, 2013.
Retrieved September 9, 2014 from http://www.reuters.com/article/2013/06/20/us_usa_health-
caregivers-idUSBRE95j03x20130620.
Bruhn, J. G., & Rebach, H. M. (2014). The sociology of caregiving. New York: Springer.
Family Caregiver Alliance, National Center on Caregiving (2012). Retrieved September 9, 2014
from https://www.caregiver.org/national-center-caregiving.
George, L. K. (1993). Sociological perspectives on life transitions. American Sociological Review,
19, 353–373.
Marks, N. F., Lambert, J. D., & Choi, H. (2002). Transitions to caregiving, gender, and
psychological well-being: A prospective U.S. National Study. Journal of Marriage and Family,
64, 657–667.
McMillan, S. C. (2005). Interventions to facilitate family caregiving at the end of life. Journal of
Palliative Medicine, 8(Suppl. 1).
National Center on Caregiving and AARP (2004). Caregiving in the U.S.
National Alliance for Caregiving and AARP (2009). Caregiving in the U.S. Retrieved August 9,
2014 from http://assets.aarp.org/rgcenter/il/caregiving_09_espdf.
Scott, E. (2014). Common causes of caregiver stress. Retrieved January 6, 2014 from http://
stress.about.com/od/copingwithcrisis/a/caregiver080507.htm.
Sheehy, G. (2011). Passages in caregiving: Turning chaos into confidence. New York: Harper
Collins.
Spillman, B. C., & Pezzin, L. E. (2000). Potential and active family caregivers: Changing networks
and the Sandwich Generation. The Milbank Quarterly, 78(3), 347–374.
Suthers, K. (2006). Women still shouldering the burden: Caregiving in the 21st century. In National
Women’s Health Network Newsletter, May/June 2006.
Wheaton, B. (1990). Life transitions, role histories and mental health. American Sociological
Review, 55(April), 209–223.