Archived project

National Military Family Bereavement Study

Goal: www.militarysurvivorstudy.org

The National Military Family Bereavement Study is the first large scientific study of the impact of a U.S. service member death on surviving family members. The research is being conducted by Uniformed Services University of the Health Sciences (USUHS) Center for the Study of Traumatic Stress (CSTS) in Bethesda, Maryland. The multi-disciplinary research team is led by Stephen J. Cozza, M.D., Associate Director of CSTS/Director of the Child and Family Program.

The death of a family member is a life-changing event for the entire family. Although bereavement eventually occurs in every family, not all bereaved persons grieve in the same way. Surviving members of military families may offer a unique perspective to understanding grief. From the initial distress of notification to longer-term challenges, family members face difficult emotional and practical issues possibly related to distinctive characteristics of military death. However, families impacted by a U.S. military death may also possess unique protective factors that affect their bereavement process and experience of loss.

There is a lack of substantive research on the impact of the death of a family member serving in the U.S. military. The need to study individual and family bereavement when a U.S. military service member dies is critical to understanding the experience of grief and loss in this unique survivor population.

This study’s findings will help to provide a scientific basis to inform policies effecting survivor care. This study seeks to better understand the impact of a service member’s death on his or her family of origin and family of procreation. The study investigates the impact of community support and services on the bereaved and how available resources impact resilience or vulnerability in surviving families. Finally, this study builds on the growing evidence addressing the intersection of grief and trauma and its effects on military family member's bereavement process.

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Project log

Stephen Cozza
added a research item
"For Children of Valor: Arlington National Cemetery" is dedicated to helping children and families of the fallen buried here to cope with their loss. The Arlington National Cemetery Commemorative Project produced the book in conjunction with illustration and photography support from the Washington Post. Dr. Stephen J. Cozza, a retired Army colonel, advised and helped author portions of the book. Cozza is a psychiatrist and expert in child trauma currently serving as a professor with the Uniformed Service University of Health Sciences, Children's author Linda Tyler wrote the main text, and artist Deborah Withey illustrated the book. The 52-page book is filled with somber images of children and families visiting the cemetery, as well as colorful patriotic graphics typical of an elementary school arts-and-craft project. Educational messages and information about Arlington cemetery history appear on the pages. There is also a section of artwork toward the back of the book for children to color in themselves.
Stephen Cozza
added a research item
Background: Bereavement by sudden and violent deaths can lead to increased grief severity, depression, and reduced posttraumatic growth compared to those bereaved by natural causes. These outcomes can be affected by coping strategies and whether a survivor had been “prepared” for the death. The present study examined the effect of coping and considering the possibility of death on grief severity, depression, and posttraumatic growth in those bereaved by sudden deaths. Methods: Participants bereaved by suicide, accident, or combat deaths completed an online survey about demographics (including the cause of death), coping, grief severity, depression, and posttraumatic growth. A factor analysis of the coping measure yielded factors representing three coping strategies: avoidant coping, supportive coping, and active coping. These three strategies, the causes of death and considering the possibility of death were used as predictors of either grief severity, depression, or posttraumatic growth in multivariate linear regression models. Results: Each coping strategy and cause of death was differentially associated with grief severity, depression, and posttraumatic growth. Specifically, supportive coping and active coping were each only associated with higher posttraumatic growth. In contrast, avoidant coping was associated with all outcomes (higher grief severity and depression and lower posttraumatic growth). In addition, accidents and suicides (compared to combat deaths) had independent effects on grief severity and posttraumatic growth. Considering the possibility of death interacted with avoidant coping and also with supportive coping to predict grief severity in combat-loss survivors. Discussion: Findings highlight the differential contributions of coping strategies and their complex relationships with cause of death in contributing to grief severity, depression, and posttraumatic growth. Avoidant coping contributed to negative outcomes and inhibited posttraumatic growth, suggesting its importance as a target for therapeutic intervention. Although supportive and active coping facilitated posttraumatic growth, they had less of a role in mitigating grief severity or depression in this study. Although considering the possibility of death appeared to mitigate negative outcomes among survivors of combat death, avoidance of that possibility is likely protective for the majority of family members whose loved ones return home safely.
Stephen Cozza
added a research item
Human Remains, Grief, and Posttraumatic Stress in Bereaved Family Members Fourteen Years after September 11, 2001, a forthcoming manuscript in the Journal of Traumatic Stress describes the mental health effects on 9/11-bereaved family members after being notified (often multiple times) that remains of their loved ones were identified. Although returning human remains to family members has traditionally been thought to support grief adaptation, 9/11 family members in this study indicated that notifications of remains identification were not associated with reduced grief severity, but with posttraumatic stress. As a result, the authors concluded that “[t]he goal for comprehensive identification must be balanced with the potential consequences of providing multiple, often distressing, notifications to family members.” One could imagine that future mass casualty events involving loss of life, whether due to explosive events resulting in fragmentation of bodies or other large scale losses, would likely lead to similar grief and posttraumatic outcomes.
Joscelyn E. Fisher
added a research item
Background: Bereavement is associated with cognitive difficulties, but it is unclear whether these difficulties are associated with normative and/or complicated grief (CG) and how comorbid depression and anxiety contribute to them. Self-reported "minor errors in thinking" (i.e., cognitive failures) may manifest following bereavement and be differentially affected by CG, anxiety, and depression. Methods: Associations between perceived cognitive failures and CG, anxiety, and depression were investigated in 581 bereaved participants. To examine both single and comorbid conditions across the spectrum of bereaved participants, these relationships were examined using both linear regressions and group comparisons. Results: Continuous measures of depression, anxiety, and grief each independently predicted perceived cognitive failures. Group comparisons indicated that the group with three comorbid conditions had the highest frequency of perceived cognitive failures and the group with no conditions had the lowest. In addition, groups with threshold depression levels (both alone and comorbid with another condition) had higher frequencies of perceived cognitive failures than other groups, suggesting that depression was more strongly associated with perceived cognitive failures than CG or anxiety. Conclusions: Future research about cognition following bereavement should address how multiple mental health symptoms or conditions combine to affect perceived and actual cognitive capacity.
Stephen Cozza
added a research item
Background/objectives: Bereavement is associated with increases in prevalence of mental health conditions and in healthcare utilization. Due to younger age and bereavement by sudden and violent deaths, military widows may be vulnerable to poorer outcomes. No systematic research has examined these effects. Method: Using outpatient medical records from wives of active-duty military service members (SMs), we compared the prevalence of mental health conditions and mental healthcare visits among case widows (n = 1,375) to matched (on age, baseline healthcare utilization, SM deployment, and rank) nonbereaved control military wives (n = 1,375), from 1 year prior (Yr-1) to 2 years following (Yr+1 and Yr+2) SM death. Prevalence risk ratios and confidence intervals were compared to determine prevalence rates of mental health conditions and outpatient mental healthcare visits over time. Results: The prevalence of any mental health condition, as well as a distinct loss- and stress-related mental health conditions, significantly increased from Yr-1 to Yr+1 and Yr+2 for cases as did mental healthcare utilization. Widows with persistent disorders (from Yr+1 to Yr+2) exhibited more mental conditions and mental healthcare utilization than widows whose conditions remitted. Conclusion: Bereavement among military widows was associated with a two- to fivefold increase in the prevalence of depression, posttraumatic stress disorder, and adjustment disorder postdeath, as well as an increase in mental healthcare utilization. An increase in the prevalence of loss- and stress-related conditions beyond 1 year after death indicates persistent loss-related morbidity. Findings indicate the need for access to healthcare services that can properly identify and treat these loss-related conditions.
Stephen Cozza
added a research item
The dead affect us in many ways – in our grief and despair, by evoking memories from the past or visiting us in our dreams, in the ways we pay tribute and memorialize the deceased, or through the hope and promise of reuniting with our loved ones following our own deaths. Death impacts us most viscerally in the material form of the human corpse. In his book, The Work of the Dead, Thomas Laqueur describes the dead body as “[t]his thing – this inanimate thing – that is always more than a thing has been the stuff of our imaginations since the beginning. We need it. It does massive work for the living” (Laqueur, 2015, p. xiv). The “work” that dead bodies do is social in nature. Bodies draw families and friends together for funerals. They serve as testaments to the noble deeds of the individuals who inhabited them or as witnesses to the misdeeds of those that may have harmed them. Collectively, dead bodies connect the living to the past, and their burial sanctifies the ground in which they are interred. In The Politics of Mourning and Who Owns the Dead? Micki McElya and Jay Aronson each detail how the human remains of those who died in a shared experience and with special significance generate profound and lasting social and political effects. These books also present striking contrasts in how the type of death (military service versus terrorism) and condition of the deceased body (human corpses versus fragmented or no human remains) powerfully impact those effects.
Stephen Cozza
added a research item
Background Distinguishing a disorder of persistent and impairing grief from normative grief allows clinicians to identify this often undetected and disabling condition. As four diagnostic criteria sets for a grief disorder have been proposed, their similarities and differences need to be elucidated. Methods Participants were family members bereaved by US military service death (N = 1732). We conducted analyses to assess the accuracy of each criteria set in identifying threshold cases (participants who endorsed baseline Inventory of Complicated Grief ⩾30 and Work and Social Adjustment Scale ⩾20) and excluding those below this threshold. We also calculated agreement among criteria sets by varying numbers of required associated symptoms. Results All four criteria sets accurately excluded participants below our identified clinical threshold (i.e. correctly excluding 86–96% of those subthreshold), but they varied in identification of threshold cases (i.e. correctly identifying 47–82%). When the number of associated symptoms was held constant, criteria sets performed similarly. Accurate case identification was optimized when one or two associated symptoms were required. When employing optimized symptom numbers, pairwise agreements among criteria became correspondingly ‘very good’ (κ = 0.86–0.96). Conclusions The four proposed criteria sets describe a similar condition of persistent and impairing grief, but differ primarily in criteria restrictiveness. Diagnostic guidance for prolonged grief disorder in International Classification of Diseases, 11th Edition (ICD-11) functions well, whereas the criteria put forth in Section III of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are unnecessarily restrictive.
Stephen Cozza
added a research item
Military service deaths result from a variety of causes but most are sudden and violent. Bereaved military family members appear to share similar outcomes to civilians who are faced with sudden and violent deaths, and a small but significant number of military family survivors suffer with persistent and impairing grief. Bereaved military families represent a broad group of individuals who vary in the challenges that they face and their resultant needs. They must negotiate a maze of military-related and complicated systems in order to manage funerary, financial, death benefit, insurance, housing, and health benefit decisions that result after the death of a military service member. Whether the cause of death be due to combat, accident, suicide, or other circumstance, the military has adopted certain policies and procedures to support families in the aftermath of a death related to military duty.
Stephen Cozza
added a research item
Background The World Health Organization (WHO) International Classification of Disease (ICD-11) is expected to include a new diagnosis for prolonged grief disorder (ICD-11 PGD ). This study examines the validity and clinical utility of the ICD-11 PGD guideline by testing its performance in a well-characterized clinical sample and contrasting it with a very different criteria set with the same name (PGD PLOS ). Methods We examined data from 261 treatment-seeking participants in the National Institute of Mental Health (NIMH)-sponsored multicenter clinical trial to determine the rates of diagnosis using the ICD-11 PGD guideline and compared these with diagnosis using PGD PLOS criteria. Results The ICD-11 PGD guideline identified 95.8% [95% confidence interval (CI) 93.3–98.2%] of a treatment-responsive cohort of patients with distressing and impairing grief. PGD PLOS criteria identified only 59.0% (95% CI 53.0–65.0%) and were more likely to omit those who lost someone other than a spouse, were currently married, bereaved by violent means, or not diagnosed with co-occurring depression. Those not diagnosed by PGD PLOS criteria showed the same rate of treatment response as those who were diagnosed. Conclusions The ICD-11 PGD diagnostic guideline showed good performance characteristics in this sample, while PGD PLOS criteria did not. Limitations of the research sample used to derive PGD PLOS criteria may partly explain their poor performance in a more diverse clinical sample. Clinicians and researchers need to be aware of the important difference between these two identically named diagnostic methods.
Stephen Cozza
added a research item
Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief-related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than six months who endorsed an elevated level of grief. A confirmatory factor analysis and test of measurement invariance of factor structure were used to compare the factor structure of their Inventory of Complicated Grief (ICG) responses to that of a bereaved non-military-related clinical research sample with similar grief levels. Results confirmed an equivalent five-factor structure of the ICG in both the military family sample and the clinical research sample. The similarity in factor structure was present despite differences in demographic characteristics and bereavement experiences between samples. Thus, the ICG reliably measures persistent and elevated grief in military family samples and provides grief symptom profiles that facilitates better understanding of their grief-related needs.
Stephen Cozza
added 4 research items
Background Self-directed multimedia resources that provide psycho-educational information to selected populations have been supported in child health related areas including parenting skills in adults and literacy in children. Comparable programs for use with bereaved children and families have not been adequately developed or empirically examined. Examining usability and satisfaction with such materials is critical, especially when dealing with bereavement. Objective This study evaluated the feasibility of the multimedia kit “Talk, Listen, Connect III: When Families Grieve™ (TLC III)” for use with caregivers and their parentally bereaved children (ages 2–16 years). Primary outcomes included the utilization and overall satisfaction with the TLC III kit and the kit’s impact on caregiver–child communication. Secondary outcomes, engagement, family coping, and caregiver and child grief also were examined. Participants Ninety-three caregivers completed pre- and post-viewing questionnaires (59 in the TLC III group, 34 in the comparison group). Results Caregiver’s who viewed the TLC III kit materials reported greater satisfaction with kit materials and greater impact on family coping with death than did caregivers who viewed the Ready kit. No significant differences were found with regard to pre- to post-test changes on any of the primary or secondary outcome measures after controlling for pretest scores. Conclusions Multimedia programs should be considered as adjuncts or alternatives to traditional therapies and further evaluated for use with parental bereavement; particularly among inaccessible segments of the population. Future studies should consider innovative approaches to examining the effects of such programs on complex problems faced by children.
Are complicated grief criteria better for diagnosing grief disorder than prolonged grief disorder criteria?—Yes.
Stephen Cozza
added 2 research items
BACKGROUND: U.S. military service members die from a variety of causes (i.e., accidents, combat, illnesses, homicide, suicide, and terrorism) while on duty and in greater numbers during times of war, leaving behind bereaved dependent family members. Identifying characteristics of these dependent families improves our understanding of their unique needs, helps educate service providers who offer assistance to these surviving family members, and better informs policy addressing their health and well-being. This study describes deceased U.S. military service members (DSMs) who died on active duty between September 11, 2001 and September 11, 2011 and their surviving dependent spouses and children. METHODS: Characteristics of DSMs (service branch, rank, and cause of death) and characteristics of spouse-with-children and spouse-only families (ages of dependents, time since loss, and distance from a military installation) were examined. RESULTS: 15,938 DSMs died from a variety of causes (e.g., accidents, combat, and illnesses). 55% of DSMs had dependent spouses and 56% of those spouses had children. Most surviving dependent spouses and children were young (mean ages = 32.8, 10.3 years; SD = 9.3, 7.3 years, respectively) at the time of DSM death. Many of these young dependents were related to a DSM who experienced a sudden and violent death. 60% of spouse-with-children families and 58% of spouse-only families lived farther than 60 miles from a military installation. Time since loss (range = 1.3-11.3 years) did not predict distance to installation. CONCLUSIONS: Findings characterize surviving spouses and their children, suggest potential risk for problematic grief outcomes, and underscore the importance of educating service providers about how to support military survivor family health and resilience.
TO THE EDITOR: Smid and Boelen rightfully highlight the importance of identifying standards for diagnosing clinically impairing grief. This issue has been of clinical interest within the United States and internationally, leading to the proposed DSM-5 persistent complex bereavement disorder criteria, as well as newly defined ICD-11 criteria for a similarly impairing grief-related condition. Such criteria will enable clinicians to better identify cases requiring evidence-based treatment.
Stephen Cozza
added 10 project references
Stephen Cozza
added a project goal
The National Military Family Bereavement Study is the first large scientific study of the impact of a U.S. service member death on surviving family members. The research is being conducted by Uniformed Services University of the Health Sciences (USUHS) Center for the Study of Traumatic Stress (CSTS) in Bethesda, Maryland. The multi-disciplinary research team is led by Stephen J. Cozza, M.D., Associate Director of CSTS/Director of the Child and Family Program.
The death of a family member is a life-changing event for the entire family. Although bereavement eventually occurs in every family, not all bereaved persons grieve in the same way. Surviving members of military families may offer a unique perspective to understanding grief. From the initial distress of notification to longer-term challenges, family members face difficult emotional and practical issues possibly related to distinctive characteristics of military death. However, families impacted by a U.S. military death may also possess unique protective factors that affect their bereavement process and experience of loss.
There is a lack of substantive research on the impact of the death of a family member serving in the U.S. military. The need to study individual and family bereavement when a U.S. military service member dies is critical to understanding the experience of grief and loss in this unique survivor population.
This study’s findings will help to provide a scientific basis to inform policies effecting survivor care. This study seeks to better understand the impact of a service member’s death on his or her family of origin and family of procreation. The study investigates the impact of community support and services on the bereaved and how available resources impact resilience or vulnerability in surviving families. Finally, this study builds on the growing evidence addressing the intersection of grief and trauma and its effects on military family member's bereavement process.