Journal of Gerontological Nursing

The Significance of Losing Things: FOR NURSING HOME RESIDENTS WITH DEMENTIA AND THEIR FAMILIES

Bethel Ann Powers, RN, PhD

Abstract

ABSTRACT

This article examines the significance of losing things as part of an individual's whole experience with the material aspects of life. The data on which this report is based were drawn from a broader ethnographic study of everyday ethics affecting nursing home residents with dementia. Combined anthropological methods of participant observation and in-depth interviewing were used to gather information about ordinary daily issues for residents, family members, and nursing home staff. Findings are described as themes related to personal possessions and concerns surrounding them. Discussion comprises an interpretive analysis of meanings drawn from the research and represented as ethical considerations and practice implications - general principles and strategies.

Abstract

ABSTRACT

This article examines the significance of losing things as part of an individual's whole experience with the material aspects of life. The data on which this report is based were drawn from a broader ethnographic study of everyday ethics affecting nursing home residents with dementia. Combined anthropological methods of participant observation and in-depth interviewing were used to gather information about ordinary daily issues for residents, family members, and nursing home staff. Findings are described as themes related to personal possessions and concerns surrounding them. Discussion comprises an interpretive analysis of meanings drawn from the research and represented as ethical considerations and practice implications - general principles and strategies.

Persons with dementia often lose things. They may put an article down and forget what they did with it. They may put away or hide things in unusual places, rummage and hoard, or take things that do not belong to them. In nursing home settings, the inability of some residents with dementia to distinguish their own belongings from those of others causes problems for fellow residents, families, and staff. Indeed, fear of loss or theft of residents' personal effects results in advising that they refrain from bringing anything of value into the nursing home. But how is the value of personal objects determined, and what is the significance of losing things for nursing home residents with dementia and for their families? In this article, the ethical and practical relevance of these questions is explored. The purpose is to draw attention to meanings associated with possessions or possession loss that illustrate the importance of helping individuals with dementia maintain connections with familiar objects of material culture.

BACKGROUND

Personal belongings have great symbolic meaning. They serve as identity markers that help to define individuals. For instance, images of individuals as they are or as they wish to be seen are projected through clothing and various accessories (e.g., jewelry, cosmetics). The images are retained in others' memories of how that person usually appears. Loss of such an "identity kit" in certain situations (e.g., institutionalization) disrupts habitual patterns of self-presentation (Goffman, 1961), and presents unfamiliar images to family and acquaintances.

Individuals have emotional attachments to their possessions. Favorite objects provide familiar comfort, bring back memories, or are admired for some perceived intrinsic quality such as beauty. There is pride associated with the acquisition of valuable possessions. Gifts and treasures passed down through generations offer a sense of continuity and personal connection. Satisfaction can be found in things that represent personal achievements and contributions. There is security in the availability of accumulated objects that support everyday roles and occupations, and pleasure in the nearness of possessions that signify compelling interests, enjoyable pursuits, and restful pastimes.

Individuals describe the trauma of losing material things as a result of house fires and other disasters as emotionally painful, psychologically disorienting, and physically upsetting (Keane, Pickett, Jepson, McCorkle, & Lowery, 1994; Murphy, 1984; Stern & Kerry, 1996). Individuals separated from their possessions in circumstances such as institutionalization or imprisonment may suffer similar effects when they lose the ability to retain material connections with their former lives (Butler, Lewis, & Sunderland 1998; Franiti, 1955; Goffman, 1961). Furthermore, results of a small experiment involving medical students' reactions to color slides of patients demonstrated that institutionalized elderly adults surrounded by personal possessions were viewed more positively by respondents than the same individuals in bare surroundings (Millard & Smith, 1981).

Social exchange theory (Blau, 1964; Emerson, 1962) offers another way to view the role of possessions. This perspective explains processes of human interaction in terms of power relationships. For example, KayserJones (1981) commented on the relative abilities of nursing home residents to parlay material resources (e.g., presents, treats, favors) for services. Access to resources enabling reciprocation led to more balanced relationships between residents and staff. In contrast, residents' lack of resources created imbalance in social exchange relationships, resulting in feelings of powerlessness and humiliating dependency. In her study of two homes for older adults, Schmidt (1982) similarly observed

the power-dependence relationships appeared to be determined by the residents' social resources - all the assets that enabled them to reward a favor, extort a concession, or do without - and by the conditions of patienthood that limited their use (p. 157).

The gerontological literature on personal possessions is neither large nor recent. The Philadelphia Geriatric Center study in the early 1980s explored the role of possessions in maintaining personal identity in late life as part of a larger investigation of older adults' sense of attachment to and feelings about their homes (Rubinstein, 1987). Most informants (N = 88) could readily identify significant objects that represented themselves, connections to others, and to the past; provided satisfaction; or served some other purpose.

Interest in what possessions mean to individuals mainly has focused on the role possessions play in adjustment to change in later life. In a study of 75 elderly women relocating to smaller apartments, degree of possession loss was identified as an important determinant of the difficulty of the move (McCracken, 1987). Findings suggested that change resulting from the necessary relinquishing of personal effects was more difficult for the women than changes in social support. The need to recognize the meaning of possessions that are useful, evoke memories, and allow continuation of important social roles also was stressed.

Results of another study of 100 men and women relocating to nursing homes indicated that individuals with cherished possessions were better adapted than those who were without (Wapner, Demick, & Redondo, 1990). Recommendations included:

* Pre-nursing home planning regarding disposition of older individuals' property.

* Implementing nursing home policies and procedures recognizing the adaptive role of residents' personal belongings.

Table

TABLE 1THE VALUE OF PERSONAL OBJECTS

TABLE 1

THE VALUE OF PERSONAL OBJECTS

* Encouraging residents to exhibit and talk about their possessions. Finally, two studies of adaptation in old age examined the nature of cherished possessions and their relationship to life satisfaction (Sherman & Newman, 1977) and connections between possession of cherished objects and reminiscence (Sherman, 1991). Findings showed the majority of elderly adults surveyed (i.e., community-based and nursing home residents) could easily identify cherished possessions (e.g., religious items, jewelry, musical instruments, books, photographs, radios and TV sets). Possessions that induced reminiscence were associated with positive mood scores. Total lack of cherished possessions was associated with significantly lower mood and life satisfaction scores.

Positive meanings associated with personal possessions must be balanced against the work and worry of attempts to safeguard and retain them. Having things that others want imposes risks; and, the literature describes nursing home residents as particularly vulnerable to theft. However, researchers also describe theft as an overt and prevalent form of abuse and victimization that resists resolution because of many contributing factors. Some of these include (Harris & Benson, 1998, 2000; Kayser- Jones, 1981):

* Open access to residents' rooms.

* Residents' inability to keep track of belongings.

* Social distance and the lack of deterrence that close relationships between residents and others in the nursing home environment might provide.

* Low enforcement of prohibitions or punishment.

Thus, the value of personal objects for residents is relative to this known danger. Overall, some theoretical perspectives have been developed on the meaning of personal objects with specific attention to object loss through theft in nursing homes. However, there has been little pursuit of the topic in recent gerontological literature; and when aging is complicated by the presence of dementia, discussions of elderly adults' relationships to physical things in their environments generally devolve into descriptions of behaviors that are described as problematic. This article shows the significance of losing things as part of a person's whole experience with the material aspects of life.

THE STUDY

The larger ethnographic study from which data for this analysis were derived combined anthropological methods of participant observation and in-depth interviewing to gather information about ordinary experiences of residents, family members, and staff in a 147-bed, voluntary, notfor-profit nursing home (Powers, 2001). Participants were encouraged to talk about daily life patterns, living accommodations, care and services, opportunities for social and leisure activities, and what they saw as issues or concerns. Data from a sample of 30 purposefully selected resident and family dyads, and 10 ethics committee cases were augmented by interviews with staff, collection of available documents, and recorded field observations involving researcher participation in daily activities. The cognitive status of sampled residents ranged from mild or moderate (16), to severe (8), to very severe (6) impairment (Hartmaier et al., 1995).

FINDINGS

Content analysis was used to analyze data related to personal objects and issues surrounding them. Tables 1 and 2 summarize two major categories in the data (i.e., the value of individuals' possessions, the experience of losing things). Themes within these categories are illustrated by direct quotes. It is important to point out that themes, though distinct, are not mutually exclusive. Overlap exists in the sense that some examples could represent more than one theme. However, this does not diminish their ability to serve as representative markers when used for descriptive or heuristic purposes.

The Value of Personal Objects

Theme 1: Former Life Connections. This theme also describes loss and transition prior to nursing home admission. For instance, family members reported that unsafe driving was among the earliest warning signs that "something was not right" The significance individuals attached to owning and driving a motor vehicle generated a flood of emotions. One family member stated, 0He still wanted to drive; so [in taking the car away] I was the meany." There was also pain associated with breaking up residences, disposing of household goods, and taking over residents' financial affairs.

Family members reported that residents often could not comprehend the necessity behind their actions. A daughter explained, "When he visits my home, I see him looking at things that used to be in his house; and I know he doesn't understand." Some families experienced guilt (e.g., "I know she will never forgive me for selling her house"), and some elected not to tell residents their homes had been sold unless they asked. Similarly, families sought to relieve concerns about money, noting the importance residents attached to always having "paid their own way." One daughter said, "To make him feel better, I gave him a check with the account number blocked out and told him he could use that if he needed to pay for something."

Framed photographs and picture albums served as tangible links to former lives and also broadened staff members' perceptions of residents as individuals. Families used photographs to stimulate conversations about individuals in social networks. They also described evidence of residents' diminished capacities to relate to family photos as dementia progressed:

She used to recognize Dad's picture all the time. Now the pictures don't mean anything. But, I'm going to bring in some older ones to see if she recognizes her parents. That's where she seems to be right now [in her memories].

Theme 2: Self-Expression. Selfexpression is about using items such as clothing, jewelry, cosmetics, and grooming accessories to convey a sense of style and personality. Residents noticed and commented on each other's appearance. Nursing assistants applied make-up, sometimes brought in toiletries for "our ladies," and styled hair (e.g., "We buy curlers, gel and things like that [to keep in] our own little cabinet. So when we couldn't get a hairdresser today, I did her hair because it's her birthday"). Families expressed the need to respect how their relative liked to present themselves to others (e.g., "He would never want to be seen that way [unshaven]."). They were dismayed when residents' behavior made grooming difficult (e.g., "My wife hates to visit because she remembers when Mom was really sharp - there was not a hair out of line and her clothes always looked great. Staff do the best they can; but she's in a state where she won't sit still.").

Table

TABLE 2THE EXPERIENCE OF LOSING THINGS

TABLE 2

THE EXPERIENCE OF LOSING THINGS

Theme 3: Intrinsic Value. The intrinsic value of a variety of objects was that they provided comfort and pleasure. For instance, residents frequently had their own television sets and radios for entertainment, although physical and cognitive limitations made many dependent on staff to tune them to the appropriate stations. Families conveyed individual preferences for residents unable to do so for themselves (e.g., "She always did like the radio. But sometimes I'll come in and it's on some hip-hop station. So we leave a note to please leave it on WXXX [that] has more of the songs of her era."). Other personal objects included furniture from home, religious objects, books, and toys (e.g., stuffed animals, dolls).

As residents' reading abilities declined, families reported reading to them. As residents* comprehension of the spoken word seemed to decrease, families sought simpler means of communication (e.g., "She reacts to pictures of children, so I decided that I was going to bring in some children's books-like Dr. Suess [that] she might get caught up in."). A counterpoint to giving children's toys and books to older individuals with dementia was expressed by a staff member, who said

These things are demeaning. And, it may be my prejudice showing [because] some residents really enjoy them. But I think we [need to] strengthen the skills they had prior to coming here. Like, what do you have for a man who always liked to go fishing? It's difficult to know what kinds of [leisure time] equipment to have available for people.

Theme 4: Care-Related Value. Care-related value includes consideration of common, generally expensive items such as eyeglasses, hearing aids, and dentures. Often, residents had used these devices for many years and were dependent on them to varying degrees - that is, some could not see well without their glasses or hear without their hearing aids, and others could, to some extent. Dentures were valued for their utility and what they contributed to an individual's appearance (e.g., [family member]: "She certainly doesn't look good without them."). Residents also differed in the faithfulness of their use of these appliances prior to admission (e.g., "She only wore them [dentures] to go out. She never really ate with them. We'd go out to [a local restaurant] and she'd take her teeth out-and put them in her purse."). Additionally, staff identified residents' special clothing needs and communicated these to families or a social worker. In the meantime, though, the temptation to "borrow" items from one resident who was cognitively impaired for use by another sometimes was difficult to resist.

The Experience of Losing Things

Theme 1: Resident Behaviors. Resident behaviors characteristic of some adults with dementia often existed preadmission (e.g., [family]: "He started hiding things because he thought people were trying to take them-like his medication. Then I'd have to go look for it."). Thus, when certain residents accused others of taking something belonging to them, possibilities to consider, in addition to theft, were that the item might have been misplaced, given away, thrown away, or hidden in a now forgotten place.

Those who wandered in and out of rooms rummaging and taking things were not easily tolerated by residents who were more cognitively intact (e.g., [family]: "Her favorite thing was packing bags. ..going into other patients' rooms and packing up their stuff. She thought everything was hers."). Transfer to the dementia care unit could bring relief (e.g., [family]: "It's so much better now. Ladies [on the other floor] were upset with him. [But, here] residents go hi and out of each others' rooms, and nobody worries too much about anything.").

Theme 2: Care Concerns. Missing eyeglasses, hearing aids, and dentures were perennial care concerns. A staff member said: "We seem to go through spells [when] nobody knows where they are. That's the thing.. .not knowing!" The expense of replacing these items was a concern (e.g., [family]: "She lost her dentures soon after she came here. We had new ones made; and those got lost. They're very expensive. So [the nursing home] agreed to pay for them that time. But, she kept taking them in and out."). At times staff instituted preventive action (e.g., [family]: "They don't want her wearing her glasses because she won't leave them on."). One family wondered about staff fears of being held hable: "It's not a regular practice for them to put his hearing aids in. Maybe they're concerned about responsibility for $1,000 pair of hearing aids." But, a nurse said: "Hearing aids are the worst [for some residents]. I think they feel the pressure in the ear; and then they get all the extraneous noise. There's no way they can dispel the noise [in a] busy, noisy place." "The teeth and the glasses were a big issue for us," said another family member. "But it gets to the point where you don't know what the right or wrong decision is. [We believe] they would make a difference for her. But how do you make her wear them? You can't!"

Theme 3: Theft. The uncertainty surrounding lost belongings led to fear of deliberate theft. A family member said

Sometimes things will go down in the laundry and then come back. Other things...! don't know where they are. Some I never got to mark. The new slacks she got for Christmas were gone right out of the box.

Other families reported need for caution based on prior experiences (e.g., "When my mother was in the nursing home (not this one) I could take nothing to her because it would disappear. So that's a worry as people become more demented and [less able to take responsibility for their things]."). Staff encouraged prompt reporting of missing items and tried to be alert for articles that could end up in the wrong places (e.g., wastebaskets, laundry, food trays). A nursing assistant said, "We really need a lot more eyes..." Continuing education offerings for all personnel included programs on care of residents' personal belongings, loss prevention, and the institution's policy of zero tolerance for theft.

Theme 4: Security. Examples of this theme describe individuals* concerns about safe handling and measures taken to protect personal belongings. The latter included clothes labels and locks on drawers and closets. Additionally, money was held safe for residents, though one resident said,

Now they tell you that it's your money and you can have it any time you want it; but you have to ask. I'm not used to that-And then when I do ask to have money to buy Christmas presents, they tell me "no" [resident was informed of a policy prohibiting staff from accepting gifts from residents].

Responsibility for safeguarding residents' property also was an issue. Staff found it "very difficult." Residents with lower levels of cognitive impairment tried to monitor their possessions and voiced concerns about security (e.g., "I don't understand [why things get lost] because I'm always around [and] there's no reason for anyone to come into my room."). Families reported that, as dementia progressed, residents' decreased awareness increased their fears of victimizatio. For example, one family member stated:

I don't know if [staff] are concerned about the responsibility? They tell us you can't leave belongings out-that [residents] come into each other's rooms, see something, and have no concept that it belongs to somebody else. And I don't mean to begrudge the patients because they seem to be oblivious to the [meaning of] personal effects... [But] we have seen evidence of things missing and misplaced.

DISCUSSION

The significance of losing things is bound up in the meaning of the things themselves and experiences associated with them. The following interpretation first identifies ethical issues embedded in the cultural context of resident life. These issues are posed as questions that are subsequently discussed as ethical considerations. Overall conclusions then are presented as practice implications (summarized in Table 3).

Cultural Context

Although it may be good to think of it as the residents' home, a nursing home is not a private residence. It is a very public place. Availability of personal space within it limits the type and amount of possessions residents may bring inside. What is acceptable to bring to a nursing home? One resident said, "I really wanted to bring my bed, but they said 'No,' so I have a terrible time sleeping." Residents already have lost so much - so many symbols of freedom (e.g., cars, homes, money) and objects of comfort (e.g., familiar surroundings and the "stuff of their everyday lives).

Ethical issues. Who can place a value on these things? Who can say what residents need most in their present and remaining days?

Added to the above considerations is that behaviors noticed in home environments, such as losing or hiding things and accusing others of stealing, may persist in the nursing home. However, what will complicate matters is that it may be true that, in the nursing home, things have been taken by other residents who cannot discriminate between the belongings of others and their own or have been deliberately stolen by nursing home employees.

Ethical issues. Who is responsible when residents with dementia lose things or take items that belong to others? If residents seems to have no interest in the objects that surround them, does it matter? Should nursing home employees be doubtful about complaints of theft made by residents whose cognitive impairment makes it difficult for them to keep track of their possessions?

Residents have rights, but little power, over their daily lives. Availability of and control over personal resources are limited. Without the aid of expensive devices (e.g., eyeglasses, hearing aids, dentures), some may be disadvantaged functionally as well.

Ethical issues. What is an acceptable quid pro quo in residents' relationships with others? Should residents be denied the use of expensive devices that easily could be lost or destroyed?

Ethical Considerations

These aforementioned clusters of ethical issues and questions pertain to the significance of losing things for nursing home residents and their families.

Who can place value? Who can say -what residents need most? Ostensibly, residents and their families are responsible for decisions about the disposition of personal possessions. However, the nursing home environment influences these decisions. Factors such as health and safety regulations, availability of space, and security concerns may inhibit individual choices to have valued possessions close at hand. For example, on a dementia unit, plants that could be mistaken for food and other objects that could cause harm must be removed or kept out of reach. Keeping little that is of value may be the trade-off in special care settings emphasizing freedom of movement and minimal restraint. However, it is important to examine the nursing home's role in de facto decision-making about what personal effects residents may have. It may be that certain areas within an institution will offer particular individuals more control over their environment.

Who is responsible? Some businesses post warnings that they are not responsible for loss of a customer's personal articles. Likewise, residents are advised not to leave money and valued items unattended. However, unlike other businesses, nursing home residents live in the nursing home. In ordinary life, this advice imposes a burden. The need for precautions is indisputable, but many residents cannot safeguard their own belongings - and those who try often worry obsessively. There is a pervasive impression that little can be done about the disappearance of personal belongings in nursing homes. This only can be countered by a strong administrative stance that assumes responsibility for care of residents' possessions and for making security a top priority.

Table

TABLE 3PRACTICE IMPLICATIONS: GENERAL PRINCIPLES AND STRATEGIES

TABLE 3

PRACTICE IMPLICATIONS: GENERAL PRINCIPLES AND STRATEGIES

Does it matter? It may be difficult to assess the extent to which residents with severe dementia relate to personal objects. However, attempting to maintain residents' appearances and surroundings as they might for themselves if they were able shows respect and preserves their dignity. The presence of personal effects may help staff appreciate the uniqueness of an individual and be of comfort to families. As health care professionals, we do not know what losing memory, language, and the power to commanicate with others is like. Therefore, we cannot presume that attentiveness to and safeguarding of personal belongings does not matter to residents in these circumstances.

Should complaints of theft ever he doubted? Residents who believe their items have been stolen, but in their forgetfulness, have hidden or misplaced them, are doubly vulnerable. Accusing others may lead to hurt and resentfulness, and a reputation for being unreliable. They may become "easy prey" if their complaints are not taken seriously. Knowledge that some residents with dementia misappropriate their own and each others belongings directs attention away from the uncomfortable possibility of theft by employees. Theft cannot be ruled out in environments as open as nursing homes; therefore, failure to give residents with dementia the benefit of any doubt violates their rights. That staff who might be wrongly accused also have rights, further serves to underscore the need for sensitive, scrupulous investigation of all complaints.

What is an acceptable quid pro quo? In his essay on forms and functions of gift-giving, Mauss (1967) concluded that "charity wounds him who receives...a courtesy has to be returned (p. 63)." Yet, residents, dependent on staff for their care, often lack material resources to reciprocate. Although a kind of "no tipping" policy may protect them from exploitation, inability to repay or reward others for services rendered can threaten individuals' dignity and sense of self -worth. It may be wise to consider under what circumstances receiving small gifts (e.g., food, handmade items) from residents, such as described by Kayser-Jones (1981), may be acceptable. Gracious acceptance empowers the giver. For example, one resident delighted in saving little packages of cookies for a favorite staff member. Refusal of these offerings would have hurt her feelings and taken from her of a simple, yet meaningful, pleasure. An example of indirect social exchange might be the encouragement of residents to talk about their personal belongings, such as, "Mrs. J. was quite a horsewoman... (Would you hand me the pins while I do your hair?)," an aide remarked as she asked a resident to talk about a framed photograph in her room while assisting with a simple task. Accepting residents* gifts of themselves (e.g., assistance, affection, advice, the stories of their lives) with sincere interest, thanks, and appreciation, is another way of restoring a balance of power to social relationships that otherwise place residents at a strong disadvantage.

Should use of expensive devices be restricted? Loss or misplacement of eyeglasses, hearing aids, and dentures is a truly vexing problem. Attention often focuses on resident behaviors (e.g., removal, destruction) that limit their use. However, particularly with residents who have difficulty communicating their concerns, it is important to investigate possible bases for the behavior:

* Could improper fit be causing pain or discomfort?

* Are devices clean and in good repair?

* Do hearing aid batteries need to be replaced?

* Are ears impacted with cerumen that needs to be removed?

* Is there a problem with ambient noise? (Environmental modifications such as carpeting and other soundabsorptive treatments help decrease background noise.)

Practical steps to evaluate situations and maintain equipment should accompany systematic assessment of residents' visual, hearing, and dental status by qualified specialists. Resnick, Fries, and Verbrugge (1997) caution that sensory losses, combined with cognitive impairment, may cause a resident "to be identified as more demented than he or she truly is (p. S136)." Thus, it is important not to magnify residents' limitations by assuming no understandable reason exists for problematic behavior. The literature also reports a high degree of across- and within-individual variability in types and timing of inappropriate behaviors in dementia (Cohen-Mansfield, 1999). Therefore, restricting use of assistive devices for fear that they will be lost or damaged by residents should be carefully weighed against possibilities that certain times and types of approaches may be better for encouraging individuals to wear them.

Practice Implications

Table 3 summarizes practice implications. Some of these principles and strategies are relevant to all residents (e.g., understanding what personal possessions mean to individuals, being accountable for care of their belongings), others target issues related specifically to caring for residents with dementia. For example, residents cannot be allowed to victimize one another by misappropriating things that do not belong to them. However, persons with dementia may need to be protected from others' righteous wrath, and their behavior should not be an excuse for discounting the possibility of employee theft and failing to establish effective theft reduction programs.

Persons with dementia also may need special help. For instance, a resident's inability to care for or communicate concerns about personal effects requires focused efforts on the part of the family and staff. Resolving uncertainty about which material objects matter to residents involves taking time to know them better as individuals. Supporting residents' abilities to engage with their material environments requires more attention to use of personal objects as vehicles to enhance communication, socialization, and family involvement with other residents and staff. This is best accomplished when residents are engaged by all nursing home employees during the performance of their daily work (e.g., using conversation and complements about residents' belongings to stimulate conversation.) However, work pressures, job expectations, or staffing patterns may prevent staff from spending more time with residents and their families. Consequently, it will be important to determine if these organizational factors inhibit them from providing care that is tailored to individual resident needs.

SUMMARY

The significance of losing things for nursing home residents with dementia and their families is part of a larger whole. The whole involves the meaning of possessions, the history of past losses and its personal consequences, and ways in which nursing home culture mediates relationships with a blend of old and new things in the material environments. Ethical practice combines understanding the whole experience surrounding possession loss with finding ways to help individuals stay connected to the world of objects that sustain identity, support functionality, provide entertainment and comfort, and bind them to other persons.

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TABLE 1

THE VALUE OF PERSONAL OBJECTS

TABLE 2

THE EXPERIENCE OF LOSING THINGS

TABLE 3

PRACTICE IMPLICATIONS: GENERAL PRINCIPLES AND STRATEGIES

10.3928/0098-9134-20031101-10

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