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Emotion Regulatory Strategies in Complicated Grief: A Systematic Review
Abstract
Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsychInfo, Web of Science and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.
... For instance, people may experience "pangs" or "waves of grief" [3,4]. Current grief research is, however, dominated by cross-sectional research using retrospective self-report measures [5][6][7][8], where participants report how frequently they had specific PGD reactions over the past month. This method inherently fails to capture possible changes in grief reactions in daily life. ...
... A person may avoid loss-related stimuli out of fear that confrontation with these stimuli is unbearable [34]. It has repeatedly been found that avoidance contributes to more negative bereavement outcomes [6,34]. Our findings could provide first insights into where this avoidance takes place. ...
... Social interactions may also serve as a positive distraction from grief [36]. For instance, being in a social contact may distract people from getting stuck in rumination, which has shown to play an important role in the persistence of PGD [6]. ...
Theoretical and anecdotal work suggests that Prolonged Grief Disorder (PGD) reactions go up and down during the day. However, empirical evidence supporting this claim is lacking. It is also unknown in which context PGD reactions go up and down. Using Experience Sampling Methodology (ESM), we examined whether PGD reactions (ESM-PGD) relate to contextual factors in daily life. For 14 days, five times per day, bereaved adults (N = 53; 74% women) rated the intensity of 11 ESM-PGD reactions representing each a DSM-5-TR PGD symptom. Using mixed-effect regression analyses, we examined whether contextual factors (i.e., physical and social environments, and time of day) were associated with each ESM-PGD reaction separately. Being away from home compared to at home was associated with more avoidance. Being alone compared to in a pleasant social contact was associated with more preoccupation with the loss, intensified feelings that part of self died, and increased perception of the loss as unreal. Lastly, a later time of day related to stronger feelings of loneliness and difficulties moving on. Our findings suggest that ESM-PGD reactions may be context-dependent. This calls for a context-sensitive treatment approach, such as ecological momentary interventions.
... 11 The positive impact of grieving is boosting the individual's ability to empathize with others, understand personal life, appreciation, and gratitude to the life that had been lived for the meaning of loss, improving the life goals, improve the ability to tolerate the changes and difficulties experienced during life. 14, 15 Based on (ICD-11), complicated grief includes a prolonged sadness disorder characterized by severe, persistent sadness and dysfunction of a person's life. ...
... The experience of loss and separation from significant people in childhood will affect the individual's ability to deal with loss in adulthood. 15 Self-concept: Unrealistic ideal self, low self-esteem, identity crisis, role crisis, negative selfimage, and motivation: history of failure, low motivation, lack of appreciation. 32 Psychological Defense: low-stress tolerance threshold, history of developmental disorders, unable to restrain oneself from less positive impulses. ...
... 9 Social status: homelessness, isolated life, with negative labels (commercial sex workers, transsexualism, homosexualism), and changes in one's social role can also cause changes in emotional regulation. 15 Background: sociocultural demands, negative community stigma and lack of social support, prolonged family conflict, caregiver burden. 19 Religion and belief: History of not carrying out routine religious activities, misperception of certain teachings, followers of deviant sects. ...
Introduction: Individuals fail to follow the normative grieving process within a long time and stay in one phase, so it manifests in physiological function and disrupts their life function. This article aims to analyze the role of aspects affecting the problem of complicated grief. Methods: A literature review method used is doing a scientific article review obtained from the database. Articles were obtained by browsing online databases, such as Science Direct, EBSCO, and Proquest, with keywords "grief" or "grieving complicated". The inclusion criteria is the research article about predisposition factors causing complicated grief, reviewed by three aspects, namely biological, psychological and social. The exclusion criteria are the systematic review or meta-analysis article. Articles limited to the last ten years, from 2011 to 2020, ensure that the article is relevant to the current condition. Result: The result from this review are biological factors (genetic, neurotransmitter, health status, substance usage history, and history of having family member with mental disorder), psychological factors (personality type, family relationships, intelligence level, past experience, self-concept, and psychological defense), social factors (age, gender, education level, economic status, social status, cultural background, religion and beliefs, and place of environment). Conclusion: Predisposition factors of complicated grieving can be reviewed from three factors, namely biological, psychological and social. A right coping source is needed so that a person can go through grieving time.
... When parents experience symptoms such as excessive worry, excessive selfblame, low mood, or excessive stress, they are identified after and caused by the loss, they are part of "complicated grief [14]. " Complicated grief also increases the incidence of cardiovascular disease, diabetes, substance use, and suicide [8,15,16]. ...
... Some studies have focused only on the symptoms and factors contributing to 'normal grief ' without exploring those associated with complicated grief. Overall, according to the findings, a significant proportion of parents with perinatal loss have experienced CG [16,25]. However, the symptoms of CG following perinatal loss and its influencing factors remain unclear. ...
Background
Perinatal loss is a severe stressor that usually triggers distressing symptoms of acute grief. Moreover, acute grief can worsen with time and become a chronic debilitating state known as complicated grief. However, there is a lack of comprehensive reviews on this topic. This systematic review aims to synthesize the existing literature on complicated grief following the perinatal loss.
Methods
We systematically searched PubMed, Embase, Cochrane Library, CINAHL, ProQuest, and Web of Science to identify articles on complicated grief symptoms and influencing factors following perinatal loss. We performed a comprehensive, structured evaluation in full compliance with PRISMA guidelines.
Results
A systematic search produced 1163 results. Of these, 38 articles met the full-text screening criteria, and 10 pieces of literature met the inclusion criteria. Individuals may experience complicated grief following perinatal loss, manifesting in symptoms such as emotional reactions, physical responses, and social impairments. Furthermore, based on existing evidence, influencing factors include demographic characteristics, reproductive characteristics, marital relationships, social support, and coping strategies.
Conclusions
Complicated grief following perinatal loss is easily overlooked and has not been adequately studied. Further empirical research is needed to explore the symptoms and factors influencing this condition. A better understanding of complicated grief will help develop and optimize care strategies, informing future clinical practice and improving psychological support for individuals affected by perinatal loss.
Trial registration
PROSPERO registration number: CRD42023473510.
... Research has demonstrated a combined impact of posttraumatic stress symptoms and grief on post-event functional impairment (Pfefferbaum et al., 2001), indicating that grief may modify the processes of coping with the aftermath of trauma. Grief involves ruminative thought patterns (Eisma & Stroebe, 2021) which may thereby hinder TMT defenses from being triggered when there is an uptick in death-related anxiety. In this context, proximal defenses associated with mortality salience and death anxiety are triggered when people are consciously aware of their mortality (Pyszczynski et al., 2000). ...
... This finding suggests that grief may interfere with the defense processes activated when death anxiety arises. One potential way in which grief may interrupt the anxiety-buffering defense mechanisms is via associated ruminative thought patterns (Eisma & Stroebe, 2021). Proximal defenses that logically question the imminence of death or directly suppress/remove thoughts from consciousness (Pyszczynski et al., 2000) have been shown to be impacted by cognitive load (Pyszczynski et al., 1999). ...
On April 29, 2021, during an Ultra-Orthodox annual communal event in Meron, a crowd rush resulted in the deaths of 45 individuals. Experiencing such events may intensify death proximity (subjective nearness to death, SNtD) and death anxiety, and increase distress. Furthermore, the experience of grief following the trauma may disrupt defense mechanisms that reduce death-related anxieties. Thus, we examined the mediating role of death anxiety on the association between SNtD and distress, and the possible moderating role of grief experiences on this model. Ultra-Orthodox Israeli Jews who experienced the Meron disaster (N = 168) responded to scales assessing demographics, SNtD, death anxiety, and psychological distress. Death anxiety mediated the SNtD-distress link and grief was a significant moderator. Specifically, for individuals low in grief, the association between high death anxiety and increased distress was nullified. Findings are discussed from the perspective of Terror Management Theory.
... According to the expectations subsumed under subscale 2, if the bereaved behaves in accordance with the cognition (i.e., not forming new bonds or enjoying oneself with others) the bond to the deceased will remain and create communion, thus reducing the experience of loneliness (at first). Non-acceptance of the loss or constantly thinking about the deceased serve as emotion regulation strategies that, in the short run, reduce feelings of longing, pain, and loneliness (Boelen et al., 2006;Eisma & Stroebe, 2021). This may explain the significantly lower association between subscale 2 and levels of loneliness. ...
... This may explain the significantly lower association between subscale 2 and levels of loneliness. In the long term, however, these avoidance behaviors may lead to functional and emotional impairment that promote the development of mental disorders, such as PGD (Eisma & Stroebe, 2021). ...
Negative expectations concerning social interactions contribute to feelings of loneliness. Since loneliness is one of the most pronounced challenges for bereaved individuals, we investigated grief-specific social expectations and its association with loneliness and grief severity. Initially, we developed an Inventory of Social Expectations in Bereavement (ISEB). Its factorial and psychometric validity was then tested in a bereaved sample (N = 344; 28.3 ± 11.1 years; 74.4% female). A two-factor solution for the scale fit the data best (factor 1: "relationship to others, " factor 2: "relationship to the deceased") and demonstrated good psychometric validity. Higher ISEB-levels were associated with higher levels in grief severity and loneliness. The results suggest that individual social expectations affect the experience of loneliness after the loss of a significant other. The ISEB assesses these expectations time-efficiently and provides a basis for therapeutic interventions. Expressing expectations as probabilistic beliefs about the future renders them amenable for corrective experiences in clinical practice.
... Similarly, repetitive negative thinking and related emotion regulation strategies are associated with less favorable grief outcomes. In particular, grief rumination and avoidance of loss-related cues and associated internal experiences can lead prolonged grief symptoms to persist (for a review: Eisma and Stroebe, 2021). Higher (prolonged) grief severity also relates to more severe insomnia symptoms (Lancel et al., 2020). ...
... First, the online recruitment led to an overrepresentation of older, Western women who had lost a partner or parent due to natural causes. While this is common in bereavement research (Eisma and Stroebe, 2021), a replication in a more representative sample is warranted. Second, the data collection for the current study occurred after bereavement. ...
Abstract
Background
Insomnia symptoms are common following bereavement and may exacerbate severe and protracted grief reactions, such as prolonged grief disorder (PGD). However, typical trajectories of insomnia symptoms and risk factors for having a more chronic insomnia trajectory following bereavement are yet unknown.
Method
In the current investigation, 220 recently bereaved (≤6 months post-loss) participants, completed questionnaires assessing sociodemographic and loss-related characteristics, rumination, experiential avoidance and symptoms of (prolonged) grief and depression, on three time-points (6 months apart). We applied growth mixture models to investigate the typical trajectories of insomnia symptoms following bereavement.
Results
Three insomnia trajectory classes emerged, characterized by a resilient (47 %), recovering (43 %) and a chronic trajectory (10 %). Baseline depression symptoms best predicted the type of insomnia trajectory. At one-year follow-up, 9 %, 27 % and 60 % of participants met the criteria for probable PGD within the resilient, recovering and chronic trajectory, respectively. A parallel process model showed that temporal changes in insomnia symptoms were strongly related to changes in prolonged grief symptoms.
Conclusion
The results suggest that targeting insomnia symptoms in the treatment of PGD, particularly with comorbid depression, may be a viable option.
... to the loss, often leading to social isolation Eisma & Stroebe, 2021). Across studies, there are large positive associations between depressive avoidance and PGD symptoms Eisma et al., 2013). ...
... PGD is also positively associated with rumination, worry, and thought suppression (Eisma et al., 2013;Eisma & Stroebe, 2021). These "cognitive avoidance strategies" may be focused on the causes and consequences of the loss and the symptoms of PGD, or negative global beliefs about the self, the world, and the future . ...
... Although they did not find a relationship between CG and behavior on the AAT, high-ruminators as a group were significantly higher in CG symptoms (Eisma et al., 2015). In a 2021 review, Eisma and Stroebe summarize results of laboratory studies of loss-related behavioral avoidance in grief as "equivocal" (Eisma and Stroebe, 2021). ...
... neutral scenes). Our aim was to disentangle prior accounts of approach/avoidance behavior in CG (Eisma & Stroebe, 2021). Prior studies conflictingly indicated that people with CG show greater approach bias for both deceased-and person-related stimuli (Maccallum & Bryant, 2019) and non-social grief-relevant stimuli (Maccallum et al., 2015), while other work showed avoidance bias for deceased-related stimuli in people with high levels of grief-related rumination (Eisma et al., 2015), a common feature of CG. ...
Background: Theoretical models of complicated grief (CG) suggest that maladaptive motivational tendencies (e.g., perseverative proximity-seeking of the deceased;excessive avoidance of reminders) interfere with a person’s ability to recover from their loved one’s death. Due in part to conflicting evidence, little mechanistic understanding of how these behaviors develop in grief exists. We sought to (1) identify behavioral differences between CG and non-CG groups based on approach/avoidance bias for grief-, deceased-, and social-related stimuli, and (2) test the role of the neuropeptide oxytocin in shaping approach/avoidance bias.
Methods: Widowed older adults with (n = 17) and without (n = 22) CG completed an approach/avoidance task measuring implicit bias for both personalized and non-specific grief-related stimuli. In a double-blinded, randomized, counterbalanced design, each participant attended both an intranasal oxytocin session and a placebo session. Aims were to (1) identify differential effects of CG and stimulus type on implicit approach/avoidance bias [placebo session], and (2) investigate interactive effects of CG, stimulus type, and oxytocin vs. placebo on approach/avoidance bias [both sessions].
Results: In the placebo session, participants in the non-CG group demonstrated an approach bias across all stimuli. Intranasal oxytocin had an overall slowing effect on the CG group’s response times. Further, oxytocin decreased avoidance bias in response to photos of the deceased spouse in the CG group only.
Conclusions: Findings support the hypothesis that oxytocin has a differential effect on motivational tendency in CG compared to non-CG, strengthening evidence for its role in CG. Findings also emphasize the need to consider differences in personalized vs. generic stimuli when designing grief-relevant tasks.
Clinical Significance: The interplay of approach and avoidance contributes to chronicity of complicated grief, and the neuropeptide oxytocin is proposed to be a key neuromechanistic component in this interaction. This study demonstrates that intranasal oxytocin administration decreased avoidance bias for pictures of the spouse in those with complicated grief, suggesting that motivational behaviors related to the reminder of the spouse are modulated by oxytocin in the brain.
... We conducted a brief study quality assessment for studies with dissimilar designs, in line with Eisma and Stroebe (2021), who rated research according to six criteria. First, we established whether studies provided a comprehensive description of sample characteristics (i.e., included the following information: gender, age, time since loss, relationship with the deceased, cause of death, or all of the previous characteristics except one; 1 point) vs. non-comprehensive description (i.e., two or more sample characteristics missing; 0 point). ...
... Second, study samples predominantly included female, middle-aged bereaved adults. While this is common in bereavement research (Eisma & Stroebe, 2021), it potentially limits the generalizability of findings. Third, adult attachment was frequently operationalized along dimensions of attachment anxiety and attachment avoidance while a limited number of investigations directly examined persons classified with specific attachment orientations. ...
Diagnoses characterized by severe, persistent and disabling grief have recently been added to the ICD-11 and DSM-5-TR as prolonged grief disorder. Adult attachment is widely assumed critical in the development, persistence, and treatment of prolonged grief, yet a meta-analysis on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42021220511) searching PsycInfo, Web of Science, and PubMed (final search: August 2022) to identify and summarize quantitative research examining relationships between adult attachment (i.e., attachment anxiety, attachment avoidance, secure attachment, disorganized attachment) and prolonged grief symptoms. Thirty-one studies including 8347 bereaved adults were included. Attachment anxiety (r = 0.28, 95 % CI:0.23-0.32, k = 15) and attachment avoidance (r = 0.15, 95 % CI:0.05-0.26, k = 15) related positively to prolonged grief symptoms concurrently. We found no evidence of publication bias but did detect heterogeneity in effect sizes. Ten longitudinal analyses showed no evidence that insecure attachment styles increase prolonged grief symptoms. Attachment anxiety predicted better therapy outcomes. Insecure attachment styles are concurrently positively related to prolonged grief symptoms but do not increase grief severity. The role of adult attachment in contemporary grief theories may need reconsideration. Intensive longitudinal research should aim to clarify how dynamic changes in attachment to the deceased and others relate to changes in prolonged grief symptoms.
... These conceptual differences are paralleled by different theoretical models of each disorder, with PTSD being characterized by fear and avoidance, and PGD being marked by longing for the deceased. There is much evidence that both PTSD (Yufik & Simms, 2010) and PGD (Eisma & Stroebe, 2021;Yu et al., 2017) can involve marked avoidance tendencies. Whereas both disorders can involve avoidance, there is some evidence that PGD can also involve approach tendencies towards reminders of the deceased (Boddez, 2018;Maccallum & Bryant, 2019;Prigerson et al., 2009). ...
... PTSD is postulated to be maintained by disruptions in fear networks that are maintained by avoidance of reminders of the traumatic event (Foa, 2006;Rauch & Drevets, 2009). Whereas models of PGD also emphasize the role of avoidance of reminders of the separation from the deceased (Boelen et al., 2006), which is supported by evidence of avoidance being a key factor in maintaining PGD (Eisma & Stroebe, 2021;Yu et al., 2017), PGD models also note the central role of separation from a key attachment figure and the disruption that this causes to one's identity (Maccallum & Bryant, 2013). This feature of PGD is reflected by evidence that problematic grief involves neural disturbances in reward processing networks (Bryant et al., 2021;O'Connor et al., 2008), and findings that grief is associated with approach tendencies on Stroop (Maccallum & Bryant, 2010) and approach-avoidance (Maccallum & Bryant, 2019;Maccallum et al., 2015) tasks. ...
Background: Reliving distressing memories is a core component of treatments for post-traumatic stress disorder (PTSD) and prolonged grief disorder (PGD). There is little understanding of how reliving these memories functions in the treatment of these disorders.
Objective: This study investigated whether reliving functions comparably in the treatment of PTSD and PGD, and whether it is comparably related to treatment outcome.
Method: This study conducted a reanalysis of patients with either PTSD (n = 55) or PGD (n = 45) who underwent treatments that comprised at least four sessions of reliving memories of either their traumatic experience or the loss of the deceased person.
Results: PTSD participants displayed greater habituation of distress across sessions during reliving than PGD participants. Between-session reduction in distress during reliving was associated with symptom remission in PTSD, but this pattern was not observed in PGD.
Conclusion: This pattern of findings indicates that although reliving appears to be a useful strategy for treating both PTSD and PGD, this strategy does not function comparably in the two conditions and may involve distinct mechanisms.
... When emotions are properly used, people can lead a satisfying life, whereas if emotions are out of our control, then we may experience disaster in our life, relationships, work field, etc. (Sharma & Sharma, 2011;Mishra & Laskar, 2013). Emotions are complex personal psycho-physiological processes of individuals which are sparked by personally significant events of an individual's life (Eisma & Stroebe, 2021;Wang, 2021). Hence, to become a well-rounded functioning individual, an individual must learn skills to excel in life, such as to plan, motivate, manage feelings or handle relationships. ...
The present world is changing faster than ever before.People are hence facing unparalleled challenges in their lives.Nowadays,teachers at all levels are expected to perform multiple roles with efficacy; thereby management of emotions is very important.Managing emotion depends on one’s emotional intelligence. The present study investigated whether Higher Secondary school teachers’ emotional intelligence is independent or dependent ontheir gender and teaching experience. The study communicated thatthe Higher Secondary school teachers’emotional intelligence is independent of their gender and teaching experience.
... In contrast, grief experiences may prompt individuals to engage in adaptive cognitive processes, such as acknowledging emotions without suppression and reinterpreting loss and sadness in a new context, aligning with research on the importance of acceptance and cognitive reappraisal in grief processing [61][62][63][64][65][66][67][68][69][70][71] . Furthermore, grief experiences may increase openness to seeking and receiving social support, which is beneficial in grief management [72][73][74] . ...
Psychedelic substances are garnering renewed interest for their potential therapeutic applications, yet the mechanisms by which challenging experiences during psychedelic use contribute to positive outcomes remains poorly understood. Here we present a mixed-methods investigation into the strategies individuals employ to navigate difficult psychedelic experiences and their relationship to emotional breakthrough. Qualitative analysis of accounts from psilocybin retreat participants (n = 16) informed the development of the Responses to Challenging Psychedelic Experiences Inventory (ReCiPE). In a subsequent online survey (n = 529), exploratory factor analysis of the ReCiPE revealed three primary response strategies: Acceptance and Reappraisal, Sensory Regulation and Physical Interaction, and Social Support and Disclosure. Exploratory correlation and multiple regression analyses demonstrated significant relationships between different types of challenges, response strategies and emotional breakthrough. Notably, Acceptance and Reappraisal, and Social Support and Disclosure strategies were positively associated with greater emotional breakthrough. Fear-related challenges were negatively associated with emotional breakthrough and involved fewer adaptive coping strategies. These findings elucidate the complex interplay between challenging experiences and adaptive responses in psychedelic contexts, offering insights for optimising therapeutic protocols and enhancing safety in both clinical and non-clinical settings.
... In particular, the use of avoidance strategies can provide temporary relief by pushing unwanted emotions and thoughts out of consciousness, but it can exacerbate depressive symptoms over time (32). This is because the temporary effects can be particularly problematic when an avoidant coping strategy manifests in substance use, risk-taking behavior, or social withdrawal (63). Alternatively, some people may use ECC as a means to openly express and process their emotions related to grief, which promotes a sense of emotional catharsis. ...
Background: Complicated grief is characterised by persistent low mood, intense distress and cognitive impairment. This study aimed to explore coping strategies (i.e. emotion-, problem- and meaning-centred) used by bereaved individuals facing complicated grief and how these strategies may predict psychological and cognitive outcomes. Methods: In a cross-sectional study, 20 bereaved individuals (5 males, 15 females) that aged 27 years old–65 years old (mean = 42.25, standard deviation [SD] = 9.30) were recruited following the loss of a loved one due to physical illness. Participants were screened for complicated grief and subsequently completed self-report assessments of coping strategies and depressive symptoms using Brief Grief Questionnaire (BGQ), Brief Coping Orientation to Problems Experienced (COPE) Questionnaire, Meaning-Centered Coping Scale (MCCS) and Patient Health Questionnaire-9 Items (PHQ-9). Following that, participants underwent a neurocognitive assessment of working memory using the 2-Back task. Results: Caregivers with complicated grief suffered from moderate severity of depressive symptoms (mean = 17.45, SD = 4.43) as they were coping with the losses. Furthermore, the f indings showed that MCC significantly predicted lower levels of depressive symptoms (b = −0.50, t (16) = −2.25, P = 0.04). However, coping strategies did not significantly predict working memory performance. Conclusion: These findings highlight the potential benefits of MCC in alleviating depressive symptoms in bereaved individuals and underscore its contribution to the development of grief interventions. Grief therapists can emphasise this coping strategy to promote healing and resilience in patients in the grief work.
... Another strength includes the assessment of early PGD symptoms as captured by the latest DSM-5-TR criteria. Lastly, almost 70% of people in our sample completed a practical education, while typically theoretically (i.e., [applied] university) educated people participate in bereavement research (for reviews, see Eisma and Stroebe 2021;Komischke-Konnerup et al. 2021). This renders our findings more representative of the Dutch general population. ...
Most studies examining prolonged grief disorder (PGD) in people bereaved during the COVID-19 pandemic are focused on psychopathology. However, mental health encompasses both absence of psychopathology and presence of well-being. This is the first study examining symptom profiles of early PGD and subjective mental well-being in 266 Dutch adults recently bereaved during the pandemic. Early PGD and well-being indicators were assessed with the Traumatic Grief Inventory-Self Report Plus and the World Health Organization-Five Well-Being Index, respectively. Latent class analysis identified four classes: low PGD/high well-being (32%), low PGD/moderate well-being (24%), moderate PGD/high well-being (23%) and high PGD/low well-being class (21%). People in the poorer mental health classes were more likely to be female, lower educated, suffering from a mental disorder, have a poor health status, closer kinship to the deceased, and higher risk of severe COVID-19. Classifying adults according to symptom profiles of negative and positive outcomes provides a more complete picture of mental health in bereaved people and offers potential intervention targets.
... For example, a bereaved individual may worry about the future to avoid thinking about past and present loss-related difficulties to decrease loss-related distress (Eisma et al., 2017). Higher levels of avoidance have been found to undermine adjustment to bereavement (e.g., Boelen et al., 2006;Eisma & Stroebe, 2021). Since cognitive processes like worry are malleable and thus might be altered through intervention, further research on the effects of worry on grieving would be beneficial. ...
Background & objectives:
Worry and loss-related secondary stressors appear to be important correlates of problematic grief responses. However, the relative importance of these variables in the context of established correlates of grief responding, ranging from indicators of identity disruption and demographic characteristics of the bereaved to characteristics of the loss of quality of the relationship with the deceased, is unknown. Modeling the relative associations of these factors can be problematic, given the high degree of collinearity between these variables. This study used a machine learning approach to provide accurate estimations of the relative importance of these correlates for post-loss symptom severity.
Methods and results:
A convenience sample of 428 bereaved people who had lost a parent, spouse, or child in the last 30 to 365 days completed an online survey. Random forest regression modeling examined the effects of worry and secondary stressors on symptom severity in the context of established correlates. Results indicated worry and the number of secondary stressors experienced were among the factors most strongly associated with severity of grief, depression, posttraumatic stress and problems functioning.
Conclusions:
These results also provide insight into the relative importance of worry and secondary stressors affecting grief severity to guide future research.
... The reliance on a convenience sample with a notable overrepresentation of women and highly educated participants poses potential challenges for generalizability. This is common in voluntary response samples for grief research (Eisma & Stroebe, 2021) and future studies should consider employing alternative sampling methods such as stratified sampling (e.g., Rosner et al., 2021). Online recruitment further implies that the sample was limited to people who have internet access and use social media, who generally have higher levels of education and are less likely to be part of vulnerable groups (for a review, see Newman et al., 2020). ...
The Coronavirus pandemic has hit Brazil exceptionally hard, with more than 700.000 confirmed deaths due to COVID-19, corresponding to an estimated 6.3 million bereaved people. Yet, the mental health consequences among COVID-19 bereaved Brazilians, and the associated loss-related variables have been largely unexplored. Therefore, we aimed to clarify the associations of loss-related characteristics and circumstances with prolonged grief, posttraumatic stress, and depression symptoms experienced by COVID-19-bereaved Brazilian adults. A sample of 371 Brazilian COVID-19 bereaved adults (90% women) completed an online survey. The loss of a partner or first-degree relative, a positive assessment of the healthcare received by the deceased, and the perceived helpfulness of hospital visits in the grief process significantly correlated with prolonged grief and posttraumatic stress symptoms. The findings suggest that farewell ceremonies and positive hospital care experiences may mitigate distress among COVID-19-bereaved Brazilian adults.
... In a recent meta-analysis, severe prolonged grief symptoms and severe depressive symptoms, PTSS, and anxiety symptoms were estimated to co-occur in 63%, 54%, and 49% of cases, respectively (Komischke-Konnerup et al., 2021). This overlap may be explained by shared transdiagnostic mechanisms that may underlie multiple types of psychopathologies, such as rumination or experiential avoidance (for reviews see Eisma & Stroebe, 2021;Hernández-Posadas et al., 2023;Moulds et al., 2020). ...
Prolonged grief symptoms frequently co‐occur with symptoms of depression, posttraumatic stress, and anxiety; however, little is known about how prolonged grief symptoms temporally relate to symptoms of neighboring stress‐related and affective disorders. Clarifying such associations can help elucidate which symptoms to prioritize during treatment for distressed bereaved adults. We conducted a systematic review to provide a comprehensive overview of the empirical research on the bidirectional temporal associations between prolonged grief symptoms and symptoms of depression, posttraumatic stress, and anxiety. A search of the PsycInfo, Web of Science, and Scopus databases (final search: December 2023) identified eight relevant empirical longitudinal studies utilizing lower‐level mediation (two studies), cross‐lagged panel modeling (CLPM; four studies), or random‐intercept CLPM (RI‐CLPM; two studies). The studies included a total of 2,914 bereaved adult participants. Studies showed considerable methodological heterogeneity, including different sample characteristics, study designs (e.g., measurement moments, time frames), statistical analyses, and measures. Temporal associations between prolonged grief symptoms and different types of symptoms appeared intertwined. Prolonged grief symptoms more consistently predicted symptoms of depression and posttraumatic stress across measurement waves than vice versa, tentatively suggesting that prolonged grief may be a transdiagnostic risk factor for depressive and PTS symptoms. However, this pattern was not observed in the two studies utilizing RI‐CLPM. Future research should aim to decrease methodological heterogeneity by using validated measures to capture prolonged grief symptoms, appropriate timeframes, and RI‐CLPM to clarify associations between temporal within‐person fluctuations of prolonged grief, depressive, posttraumatic stress, and anxiety symptoms.
... Emotion regulation strategies are the ways in which people try to modify their emotional experiences. There are several strategies people use to manage their emotions, such as cognitive reappraisal, positive thought, situation modification, mindfulness, and expressive suppression (Eisma & Stroebe, 2021). Different emotion regulation strategies chosen from a board repertoire will have different effects depending on situation demands (Gross, 2015;Gross & Thompson, 2007). ...
... First, our sample consisted primarily of higher educated, middle-aged women from a Western country. Overrepresentation of middle-aged females is common in grief research (Eisma and Stroebe, 2021) and may partly reflect an overrepresentation of older women in widowhood (Arbuckle and de Vries, 1995) as well as a stronger inclination to women to share their feelings (Stroebe et al., 2001). While there are no reasons to assume different outcomes in bereaved samples with lower education levels, more men, and people from different cultural backgrounds, the generalizability of current findings remains to be established. ...
Objective: Two similar but distinct versions of prolonged grief disorder (PGD) have recently been included in the International Classification of Diseases eleventh edition (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders
– fifth edition, Text-Revision (DSM-5-TR). This study provides a criterion validity test of both new criteria sets of PGD,
by examining concurrent and longitudinal associations of ICD-11 and DSM-5-TR prolonged grief symptoms with quality
of life (QOL).
Methods: Bereaved adults completed a survey assessing ICD-11 and DSM-5-TR prolonged grief symptoms, depressive
symptoms, insomnia symptoms and QOL at baseline and 6-month follow-up.
Results: Both ICD-11 and DSM-5-TR prolonged grief symptoms related negatively to QOL concurrently, while controlling for insomnia and depressive symptoms. ICD-11 prolonged grief symptoms, but not DSM-5-TR prolonged grief symptoms, predicted QOL at 6-month follow-up, while controlling for baseline QOL and insomnia and depression symptoms.
Conclusions: Results provide consistent evidence for the criterion validity of ICD-11 PGD, but mixed evidence for
the criterion validity of DSM-5-TR PGD. Study results can help guide attempts to optimize and harmonize future PGD
criteria.
... Por su efectividad en el tratamiento del duelo y con base a los hallazgos de este estudio, se propone el desarrollo de programas de intervención desde una terapia cognitivo-conductual a través de técnicas que permitan la regulación efectiva de los estados emocio-nales tanto positivos como negativos, la modulación de los procesos de rumiación y el fomento de estrategias como la reevaluación positiva, favoreciendo así el desarrollo de CPT en personas que se encuentren atravesando un proceso de duelo (Eisma et al., 2021). ...
... Related to adaptive replay, one key component of grief we did not model was avoidance behavior, an additional major driver of PGD (Eisma & Stroebe, 2021). In our simulations, replayed rewards themselves did not contribute to the agent's experienced reward, except as an explanation for why grief is painful. ...
Grief is a reaction to loss that is observed across human cultures and even in other species. While the particular expressions of grief vary significantly, universal aspects include experiences of emotional pain and frequent remembering of what was lost. Despite its prevalence, and its obvious nature, the normative value of grief is puzzling: Why do we grieve? Why is it painful ? And why is it sometimes prolonged enough to be clinically impairing? Using the framework of reinforcement learning with memory replay, we offer answers to these questions and suggest that grief may have normative value with respect to reward maximization.
... For example, people with an insecure attachment style (Currier et al., 2015), those who were more emotionally closer to the deceased (Lobb et al., 2010), and those who have problems with substance use (Parisi et al., 2019), are likely to report more severe grief symptoms. However, having more adaptive emotion regulation strategies (e.g., mindfulness) can help decrease the severity of such experiences (Eisma & Stroebe, 2021). Similarly, having stronger support systems can act as a buffer when people are struggling with the loss of a close person (Gesi et al., 2020;Levi-Belz & Lev-Ari, 2019;Mason et al., 2020), and foster personal growth and acceptance after such experience (Hogan & Schmidt, 2002). ...
Past research showed that high trait anxiety and low self-compassion, along with lack of perceived social support, have been associated with experiencing stronger grief symptoms. However, research is yet to understand if and how these factors interact among grieving individuals. Results of a cross-sectional study ( N = 539) showed that perceived social support interacted differently with trait anxiety and self-compassion to shape grief experiences. Unexpectedly, perceived social support did not buffer the association between higher trait anxiety and stronger grief symptoms. Instead, participants with higher trait anxiety reported stronger symptoms only when they perceived to have less social support. In contrast, participants with higher self-compassion reported less symptoms when they perceived to have more social support. These findings show that social support can emphasize the detrimental role of anxiety and the protective role of self-compassion when people are coping with a loss. Implications and suggestions for future research are discussed.
... The experience of bereavement in Chinese culture has been explored using different research designs, including quantitative and qualitative. There is a wide range of previous systematic reviews on bereavement experiences such as abnormal grief [13][14][15], grief measurements [16,17], interventions for bereavement [18,19] and bereavement outcomes [20]. However, no systematically constructed reviews were identified to explore such experiences for people who are influenced by Chinese culture. ...
Background
Bereavement experience is shaped by cultural and social contexts. No systematically constructed reviews were identified to explore the bereavement experience for people who are influenced by Chinese culture valuing filial piety and mutual dependence. This review aimed to systematically review the bereavement experience of Taiwanese family members living in Taiwan following an expected death.
Methods
MEDLINE, PsycINFO, CINAHL, China Academic Journal Database, and Chinese Electronic Periodical Services were searched with no date restrictions from inception to 20 October 2022. The methodological rigour of studies was assessed using Hawker’s appraisal tool. A narrative synthesis approach using Popay’s work was employed to synthesise the findings of the studies. Studies investigating Taiwanese family members’ bereavement experiences were included. We excluded papers studying bereavement through the death of a child.
Results
Searches retrieved 12,735 articles (after de-duplication), 17 of which met the inclusion criteria and were included for synthesis: English [9] and Chinese [8], published between 2006 and 2021. The studies varied in quality with scores ranging from 22 to 33 out of 36. The studies differed in the relationship between participants and the deceased, the bereaved time frames, and the definitions of bereavement. Most studies focussed on family members of cancer patients receiving specialist palliative care. Three bereavement theories and four tools were used. Risk factors of bereavement outcomes included family members feeling less prepared for death and deaths where palliative sedative therapy was used. Protective factors were higher caregiving burden and longer caregiving periods. Four themes regarding Taiwanese bereavement experience were generated: multiple impacts of death; problem-based coping strategies; importance of maintaining connections; influential religious beliefs and rituals.
Conclusion
Continuing the relationship with the deceased is a key element of Taiwanese bereavement experience and it is influenced by religious and cultural beliefs. Suppressing or hiding emotions during bereavement to connect with the deceased and maintain harmonious relationships needs to be acknowledged as culturally acceptable and encouraged by some religions in Taiwan. The findings could be potentially relevant for other Chinese populations, predominantly Buddhist countries or other East Asian societies. The role of preparing for death in bereavement outcomes is little understood and requires further research.
... Academic performance meets the expectations of society, schools, and parents, which will bring positive feedback to the students [6]. These positive feedbacks, such as praise, will improve students' self-esteem [20], and self-esteem can effectively reduce antisocial behavior [21]. According to the moral licensing theory, this kind of self-moral cognition brought by academic achievements will allow students to engage in antisocial behavior and will not be punished. ...
The school bullying incident has aroused widespread concern in current society. How to manage students’ anti-social behavior has become an increasingly serious problem for administrators. This study uses a sample of 8270 junior high school students to examine the mechanism of academic achievement on students’ antisocial behavior. The results showed that academic performance has a U-shaped impact on antisocial behavior. This study further found that the U-shaped effect of academic performance on antisocial behavior was mediated by the praise; In addition, this study also found that moral identity moderates the U-shaped relationship between academic performance, praise, and antisocial performance. The findings provide the implications for school administrators and teachers to pay attention to the "moral trap" of academic achievement and praise, and pay attention to excellent students’ moral education, to reduce the possibility of their anti-social behavior.
... 22 Grief processing correlated longitudinally with more severe distress and poorer perceived health among the bereaved, 23 and deliberate grief avoidance was found to contribute to the persistence of complicated grief. 24 Bereavement coping has an inherent social nature. People's coping styles differ across social contexts. ...
Purpose
The study aims to understand how enacted stigma influences bereavement coping at the style (scale) level and the specific pathways at the strategy (item) level.
Methods
The longitudinal data of 755 children orphaned by parental Acquired Immune Deficiency Syndrome (AIDS) in rural China were used. Grief processing and deliberate grief avoidance were measured at wave 1 (baseline) and wave 2 (one-year follow-up) to reflect bereavement coping in the contexts of being with family members, being with friends, being with community members, and being alone. Enacted stigma that measured at wave 1 was used to assess the experienced stigma of these AIDS-orphaned children. Network analyses were run following regressions.
Results
Controlling for demographics and baseline-level bereavement coping, multivariate regressions revealed that enacted stigma at wave 1 significantly predicted grief processing and deliberate grief avoidance at wave 2. Network analyses showed that, for grief processing, stigma increased searching for meaning alone and with friends and expressing feelings to community members, which then provoked the same strategy across contexts. Meanwhile, stigma triggered the deliberate grief avoidance network by initially suppressing the expression of feelings to community members.
Conclusion
Enacted stigma contributes to bereavement coping. Stigma stirs up complex feelings but forces AIDS-orphaned children to suppress expressions, and it increases needs to process grief through meaning making but cuts supporting forces by promoting avoidance. Interventions are imperative to reduce stigma, improve emotion regulation, and facilitate meaning making for people bereaved by stigmatized deaths.
... Another strength includes the assessment of acute PGD symptoms as captured by the latest DSM-5-TR criteria. Lastly, almost 70% of people in our sample completed a practical education, while typically theoretically (i.e., (applied) university) educated people participate in bereavement research (for reviews see: Eisma & Stroebe, 2021;Komischke-Konnerup et al., 2021). This renders our findings more representative of the Dutch general population. ...
Background: Most studies examining prolonged grief disorder (PGD) symptoms in people bereaved during the COVID-19 pandemic are focused on the presence or absence of psychopathology. However, mental health does not only represent absence of psychopathology, but also presence of well-being. This is the first study examining symptom-profiles of acute PGD and well-being indicators in adults recently bereaved during the first year of the COVID-19 pandemic. Method: Cross-sectional survey-data were analyzed of 266 residents of the Netherlands, bereaved on average 115 days prior. Latent class analysis (LCA) was used to determine class-membership based on acute PGD and well-being indicators (assessed with the Traumatic Grief Inventory-Self Report Plus and the World Health Organization-Five Well-being Index, respectively). Associations were examined between class-membership and socio-demographic, loss-related, health-related, and trauma-related characteristics using the three-step approach. Results: LCA revealed a four-class solution: a low PGD/high well-being class (32%), low PGD/moderate well-being class (24%), moderate PGD/high well-being class (23%), and high PGD/low well-being class (21%). People in the moderate PGD/high well-being and high PGD/low well-being classes were more likely to be female, lower educated, a nuclear family member of the deceased, currently suffering from a mental disorder, to have a poor current health status, and a higher risk of severe COVID-19 symptoms. Conclusions: Classifying adults according to symptom-profiles of negative and positive psychological outcomes, provides a more complete picture of overall mental health in bereaved people and yields information about possible intervention targets.
... This exact phenomena (emotion regulation being effective and maladaptive) is applied in models of psychopathology which attribute symptoms partly to the habitual use of avoidance (a form of situation selection or modification; including experiential avoidance) (Ellard et al., 2010;Fernández-Rodríguez et al., 2023;Hayes et al., 2006;Keane et al., 2006). While extensive research has been conducted on the effectiveness of emotion regulation strategies in clinical and non-clinical populations (Dodd et al., 2019;Dryman & Heimberg, 2018;Okur Güney et al., 2019;Picó-Pérez et al., 2017;, it is nonetheless vital to also consider the short and long-term adaptiveness of different strategies (Aldao & Christensen, 2015;Aldao et al., 2010Aldao et al., , 2016Eisma & Stroebe, 2021;Hu et al., 2014;Ludwig et al., 2019;Miles et al., 2013;Sloan et al., 2017;Troy et al., 2023;Wilson & Gentzler, 2021). Further, no strategy or tactic will be appropriate at all times for all people; it is important to identify the conditions under which a given strategy may be more or less effective or adaptive (Aldao, 2013). ...
Extensive research has been conducted regarding how people manage their emotions. Within this research, there has been growing attention toward the role of mindfulness in emotion regulation. While prior reviews have discussed mindfulness in the context of emotion regulation, they have not provided a thorough integration using the prevailing models of emotion regulation or mindfulness. The present review discusses the Extended Process Model of Emotion Regulation and Monitoring and Acceptance Theory of mindfulness in order to propose a novel integrated framework, the Dual-mode Model of Mindful Emotion Regulation (D-MER). This model proposes two “modes” of mindfulness: Implementation and facilitation. Implementation posits that mindfulness skills can be used as emotion regulation strategies through attentional deployment and cognitive change. Facilitation posits that mindfulness as a state or trait affects emotion generation and regulation through effects on cognitive processes and positive or negative valence systems. Further, the D-MER posits that mindfulness experience can improve the efficiency of mindfulness-based emotion regulation strategies (implementation) while effects of mindfulness on emotion regulation processes become increasingly trait-like and automatic over time (facilitation). Empirical and theoretical support for this model are discussed, specific hypotheses to guide further research are provided, and clinical implications are presented. Use of this model may identify mechanisms underlying the interaction between mindfulness and emotion regulation which can be used in ongoing affective and clinical research.
... In general, positive associations were found between putative maladaptive emotion regulation strategies (e.g., emotional avoidance) and complicated grief, and negative associations were seen between putative adaptive emotion regulation strategies (cognitive reappraisal, acceptance, and problem-solving) and complicated grief (Eisma & Stroebe, 2021). ...
The COVID-19 pandemic altered the way people live. For safety reasons, the government of the Philippines imposed health guidelines that affected the grieving process of Filipinos, resulting in complicated bereavement; yet there is little research examining potential protective factors for grieving Filipinos. This study investigated the mediating role of coping strategies between complicated grief and psychological wellbeing among 200 bereaved Filipinos aged 18 to 67. The researchers employed random sampling to administer modified versions of the Inventory of Complicated Grief, Coping Strategies Scale, and Ryff's Psychological Well-being questionnaires. It was determined that the degree of complicated grief was low, the level of coping strategies was high, and coping mechanisms were frequently employed. The findings indicated that coping strategies fully mediated the relationship between symptoms of complicated grief and psychological well-being (β =-.493, t = 2.16, p = .03). Implications and recommendations were discussed.
... Emotions are complex psycho-physiological processes triggered by subjectively important events in an individual's life (Eisma and Stroebe, 2021). They have been studied by psychologists for more than a century (Berridge, 2018). ...
The research studies in this Research Topic make significant contributions to the area of teachers’ emotions. Furthermore, these studies also have both theoretical and practical implications. It is suggested that teachers’ emotions cannot be regarded as isolated from social, cultural, and political environments, but they are intertwined, a process called emotional transmission in the teaching context (Frenzel et al., 2018). Therefore, teachers’ emotions are dynamic rather than static. However, most previous studies regarded teachers’ emotions as a static variable by measuring their emotions at one time and testing their relationships with other variables (e.g., students’ emotional responses; Wang et al.). A transmissive and dynamic perspective on the possible roles of teachers’ emotions is still lacking. Further work should understand the role of teachers’ emotions in educational contexts by dynamic measures (e.g., experience sampling).
... For example, people with an insecure attachment style (Currier et al., 2015), those who were more emotionally closer to the deceased (Lobb et al., 2010), and those who have problems with substance use (Parisi et al., 2019), are likely to report more severe grief symptoms. However, having more adaptive emotion regulation strategies (e.g., mindfulness) can help decrease the severity of such experiences (Eisma & Stroebe, 2021). Similarly, having stronger support systems can act as a buffer when people are struggling with the loss of a close person (Gesi et al., 2020;Levi-Belz & Lev-Ari, 2019;Mason et al., 2020), and foster personal growth and acceptance after such experience (Hogan & Schmidt, 2002). ...
Trait anxiety and self-compassion (individual factors), along with perceived social support (relational factor), have been associated with the likelihood of experiencing complicated grief (CG). However, if and how these factors interact are far from understood. Results of a cross-sectional study (N = 549), showed that perceived social support interacted differently with both trait anxiety and self-compassion to shape CG experiences. Participants with higher trait anxiety reported more CG if they perceived to have less (but not more) social support. In contrast, participants with higher self-compassion reported less CG if they perceived to have more (but not less) social support. This indicates that lacking social support can emphasize the detrimental role of anxiety, whereas having social support enhances the protective role of self-compassion, on CG experiences. We offer insights on how to improve the health and well-being of people who are struggling to cope with a loss.
... This exact phenomena (a strategy being effective and maladaptive) is applied in models of psychopathology which attribute symptoms partly to the habitual use of avoidance (a form of situation selection or modification; including experiential avoidance) (Ellard et al., 2010;Fernández-Rodríguez et al., 2023;Hayes et al., 2006;Keane et al., 2006). While extensive research has been conducted on the effectiveness of emotion regulation strategies in clinical and non-clinical populations (Dodd et al., 2019;Dryman & Heimberg, 2018;Okur Güney et al., 2019;Picó-Pérez et al., 2017;, it is nonetheless vital to also consider the short and long-term adaptiveness of different strategies (Aldao & Christensen, 2015;Aldao et al., 2010Aldao et al., , 2016Eisma & Stroebe, 2021;Hu et al., 2014;Ludwig et al., 2019;Miles et al., 2013;Sloan et al., 2017;Wilson & Gentzler, 2021). Further, no strategy or tactic will be appropriate at all times for all people; it is important to identify the conditions under which a given strategy may be more or less effective or adaptive (Aldao, 2013). ...
Extensive research has been conducted regarding how people manage their emotions. Within this research, there has been growing attention towards the role of mindfulness in emotion regulation. While prior reviews have discussed mindfulness in the context of emotion regulation, they have not provided a thorough integration using the prevailing models of emotion regulation or mindfulness. The present review discusses the Extended Process Model of Emotion Regulation and Monitoring and Acceptance Theory of mindfulness in order to propose a novel integrated framework, the Dual-mode Model of Mindful Emotion Regulation (D-MER). This model proposes two "modes" of mindfulness: Implementation and facilitation. Implementation posits that mindfulness components act as emotion regulation strategies through attentional deployment and cognitive change. Facilitation posits that mindfulness components act on emotion generation and regulation through effects on cognitive processes and positive or negative valence systems. Empirical and theoretical support for this model are discussed, specific hypotheses to guide further research are provided, and clinical implications are presented. Use of this model may identify mechanisms underlying the interaction between mindfulness and emotion regulation which can be used in ongoing affective and clinical research.
... A meta-analysis found specific relations of common adaptive strategies (e.g., acceptance, problem solving, reappraisal) or maladaptive strategies (e.g., avoidance,, rumination, and suppression) of emotion regulation to anxiety, depression, eating, and substance-related disorders in expected directions among clinical and community samples of children, adolescents, and adults (Aldao et al., 2010). In bereaved individuals, a meta-analysis found that two maladaptive emotion regulation strategies, namely, experiential avoidance (i.e., avoiding unwanted thoughts, feelings, or sensations) and grief-related rumination (i.e., repetitively thinking about the causes and consequences of negative emotions), were strong predictors of prolonged grief (Eisma & Stroebe, 2021). ...
Family-based bereavement interventions have shown promises to prevent problem outcomes and promote resilience in parentally bereaved children. Evidence of the broad range of mental and physical health problems following the death of a parent supports the need for a transdiagnostic approach that promotes adaptation and reduces multiple problem outcomes for parentally bereaved families. We discuss self-compassion as a promising framework for a transdiagnostic approach. We argue that three elements of self-compassion—mindfulness (vs. over-identification), self-kindness (vs. self-judgment), and common humanity (vs. isolation)—can facilitate loss-oriented coping, restoration-oriented coping, and the oscillation process between the two. This sets the foundation for individual and family processes that support bereavement adjustment. To explain how self-compassion promotes adjustment outcomes in parentally bereaved families, we review the extant literature with a focus on parental emotion regulation and effective parenting and propose a conceptual model with testable hypotheses to guide more research in this area. The model suggests that caregivers’ self-compassion is a resilience resource for multiple adaptive outcomes for themselves and for their child through its positive impacts on emotion regulation and effective parenting. We illustrate the utility of the framework with an example of a family-based bereavement prevention program that integrated self-compassion training. Future directions for research are discussed.
Objectives
This study aimed to examine the feasibility and preliminary effectiveness of a behavioral activation (BA) program for the bereaved of cancer patients toward reducing depressive symptoms.
Methods
The BA program for the bereaved was a partially modified version for cancer patients. This program encompassed a preinterview and seven 50-minute sessions every 1–2 weeks, using worksheets, with homework assignments each day. To examine feasibility, the completion rates of intervention and 3 months of follow-up were examined. To examine the preliminary effectiveness, psychological symptoms were assessed with the Patient Health Questionnaire (PHQ-9; primary outcome) and Beck Depression Inventory-II (BDI-II) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety. These were evaluated 3 times: before, immediately after, and 3-month post-intervention. Non-parametric tests were used for comparison of scores at 3 time points and calculation of effect size.
Results
Of the 42 bereaved who were contacted, 21 were eligible and 20 were participated, while 19 and 18 were in the completed intervention and completed 3-month post-intervention categories (intervention completion rate was 95% and follow-up completion rate was 90%). PHQ-9, BDI-II, and GAD-7 showed significant reductions immediately and 3 months after the intervention compared to pre-intervention, and the effect sizes were all large after 3 months, although they were less than immediately after (PHQ-9: 0.89, 0.71; BDI-II: 0.88, 0.67; GAD-7: 0.57, 0.53).
Significance of results
This study indicated that the BA program for the bereaved of cancer patients was feasible and effective vis-à-vis reducing depressive symptoms.
The death of a loved one is one of the most traumatic psychological experiences. As a reaction to the trauma due to the death of a loved one, a series of emotions, bodily sensations, behavior, and thought content is created. Grief is a universal reaction to death. Grieving is a process, specific to individuals and differs in duration and characteristics. The grieving process has stages and tasks, in order for the grieving person to functionally adapt to the loss. The new International Classification of Diseases (ICD-11) classifies prolonged grief as a psychiatric disorder, which significantly correlates with anxiety, depression, somatization, post-traumatic stress. The aim of this overview (theoretical) paper is to present the results of empirical research in which significant elements of the grieving process were studied. These are psychological experiences in grieving (feelings, bodily sensations, content of thoughts, forms of behavior), stages of grieving (numbness, longing, disorganization of behavior, reorganization of life), tasks of grieving (accepting the reality of loss, processing pain, adapting to the environment, emotional displacement of the deceased) and the end of grieving. In this paper, we examined the emotional connection of the grieving person with the deceased from the perspective of the theory of affective attachment. The paper may benefit individuals who are in the process of grieving, as well as professionals in the fields of mental health, counseling and grief therapy.
Background
There is established evidence of complicated grief among people with an intellectual disability. This paper describes the process of adapting complicated grief therapy (CGT) for this population.
Method
Action research documented the adaptation of CGT. Qualitative methods included analysing meeting notes, reflective interviews with two members of the team involved in adapting the materials, and interviews with six professionals working in disability settings who reviewed the adapted materials.
Results
Key processes included adapting the standardised tools that form part of CGT and developing adapted approaches to abstract concepts related to death, dying and bereavement. Key therapeutic components such as imaginal revisiting and the role of significant others required adaptation for implementation with people with intellectual disabilities.
Conclusion
The importance of adapting evidence‐based therapies for people with intellectual disabilities is emphasised. This research provides an adapted form of an established therapy for piloting with this population.
This study aims to explore the differences in prolonged grief (PDG), posttraumatic stress (PTSD), and depression symptoms (MDD) following the loss of a loved one before and after the COVID-19 pandemic. Using a cross-sectional design, 888 bereaved individuals were classified on different groups according to the cause of death. Results indicate that participants who experienced a loss during the pandemic, regardless of the cause, presented higher levels of prolonged grief, posttraumatic stress and depression when compared to those who lost a loved one before the pandemic. This study sheds light on the environmental influences (ex: the COVID-19 pandemic) on the grieving process, emphasizing the need to take the context into account when tailoring interventions in bereavement and mental health care.
For the families of the Disappeared, the legacy of the disappearance and its impact on family life was immense. The effect of the disappearance of a loved one was not just restricted to those who were old enough to have cognisance of the significance of the event at the time. For the individuals who participated in this study, it was evident that the disappearance had a profound effect across the second and even third generations. Fear was a constant companion across the generations. Part of the process of control in the aftermath of the violence was to increase fear and threaten anyone who spoke out. Overcoming this fear, taking up an activist role, and seeking justice for their loved ones was a part of the journey for the families in this volume. This chapter tracks this process and explores the trauma inflicted on the families across generations as they sought information on the disappearance of their family member.
This study aims to validate the Korean version of the Revised Prolonged Grief Disorder scale (PG-13-R-K) by exploring the psychometric properties of the revised Prolonged Grief Disorder scale in bereaved South Korean adults. A total of 694 bereaved individuals who had experienced the loss of a close person for a duration ranging from 12 to 24 months were included in this study and randomly divided into two separate datasets to conduct factor analyses. The results of both EFA and CFA revealed a single-factor structure for the PG-13-R-K. Moreover, the results of reliability and validity tests showed adequate internal consistency and concurrent validity. These findings suggest that the PG-13-R-K is a reliable and valid tool for assessing PGD symptoms among bereaved Korean adults. The limitations and implications of this study are thoroughly examined and discussed.
Against a background of scarce research into the relationship between difficulty in emotion regulation and self-compassion among bereaved populations, the aim of this study was to examine self-compassion and difficulty in emotion regulation among university students who had experienced the death of a parent (n = 150) and those who had not (n = 474). It was found that the self-compassion scores of the university students with a deceased parent were significantly lower than the scores of those with living parents. Similarly, university students whose parent had passed away had higher scores for difficulty in emotion regulation than students who had not lived through that trauma. Our results show that for university students losing a parent may be associated with less self-compassion and more difficulties in emotion regulation.
Academic results across Indian schools, except for those in Rajasthan and Punjab, have shown a decline since 2017, indicating a widening learning gap due to pandemic disruptions. The National Achievement Survey, 2021, based on exams from 1.18 lakh schools in 720 districts, evaluated students' proficiency in environmental science, language, and math. Except for Punjab and Rajasthan, all states and Union Territories scored below the national average reported in the 2017 survey. Despite some improvements in math scores, the overall performance decreased. Kerala, Punjab, and Rajasthan ranked highest, while Telangana, Arunachal Pradesh, and Chhattisgarh ranked lowest in academic performance. Teachers with high emotional intelligence (EI) can focus on the emotional aspects of learning and teaching exchanges (Mortiboys, 2005), which can directly create a positive atmosphere in the classroom to make the course more interesting and enjoyable (Miri and Pishghadam, 2021). Previous research has found a close relationship between teachers' EI and student learning. This research aims to ascertain the degree to which Palakkad district, Kerala teachers' empathy quotient affects their students' academic achievement. The study looked at how parameters like age, gender, educational attainment, years of teaching experience, and COVID-19 influences affected the determination of teaching efficacy. A computerized survey was used to gather information from Palakkad district, Kerala, India's private and public schools. The study's participants included full-time instructors working in schools of Palakkad district, Kerala. 246 school instructors answered the poll. The data were examined using ANOVA, independent sample t-test, and descriptive statistics along with the multiple regression. Necessary suggestions are made.
Insecure attachment is proposed to be a risk factor in the development and persistence of severe grief. Although prior research demonstrates positive cross-sectional and longitudinal correlations between attachment styles and prolonged grief symptoms, controlled longitudinal analyses yield fewer convincing results. Therefore, we sought to further clarify the concurrent and longitudinal associations between these constructs. A sample of 225 bereaved Dutch adults (87% women; Mean age: 48.86 years) participated in a three-wave longitudinal survey including measures of attachment anxiety and attachment avoidance at baseline and prolonged grief symptoms at baseline and 6- and 12-month follow-up. Attachment anxiety and attachment avoidance were significantly positively correlated with prolonged grief symptoms at all time-points. However, multiple regressions, controlling for baseline symptoms, showed that attachment anxiety, attachment avoidance, and their interaction did not predict residual change in prolonged grief symptoms. These findings cast doubt on the proposed role of insecure attachment styles in prolonged grief.
Aim: This research was conducted with the aim of providing a comprehensive summary of empirical evidence related to complicated bereavement. Methods: This was a qualitative research using systematic review of sources. In this regard, initially, the research literature related to bereavement during the years 2000 to 2021 were examined. The number of 547 articles were identified as related. Finally, according to the entry or inclusion criteria, 42 studies were selected and examined in the final stage. Data were reviewed by two reviewers working independently, and examined using the tool proposed by PRISMA (2009). The reviewers compared the data and discussed disagreements to reach consensus. Consensus data were used in the final analysis. Findings: Finally, data was placed in two groups: Therapeutic factors (encouraging self-regulation, sharing pain with others or restorative retelling, facing or reviewing avoidant situations, reviewing positive memories of the deceased person and inviting negative memories) and risky factors (weakness in mourning rituals, little social support, negative meaning of loss) were placed. Conclusion: Social support is especially important in the treatment of people suffering from complicated grief.
The main aim of this research was to study the role of existential need in the process of emotional transformation in the framework of Emotion-Focused Therapy within the issue of complicated grief in the context of the empty chair for unfinished business. Though the systematic and focused study of existential need and its processing is a key component of the model, it has not been carried out so far. Thus, this paper aimed, first of all, to outline a rational-empirical model concerning the processing of existential need and its involvement in the process of emotional transformation. In order to do that, the study 1 was conducted (outlined in Chapter 5). This study 1 also resulted in the Measure of Existential Need Processing in Emotion-Focused Therapy (which allows for the evaluation of the presence of the components in the therapy sessions). For this purpose, the Task Analysis method (Greenberg, 2007) was used as a resource to hypothesise the elements of the need processing model in the therapy session and their optimal order (study 1, Chapter 5), as well as to evaluate, refine and finally contrast the capacity of the final model and it’s components to lead to therapeutic change and resolution of the empty chair task (study 2, Chapter 6). Similarly, sequence analyses of the different components of the existential need model were also conducted to establish their prototypical order in the processing of existential need (study 2, Chapter 6). In this study 2 Existential Need Processing Scale was also developed. For this purpose, a sample of 30 people experiencing complicated grief was taken, with whom 3 sessions were held in telematic format (videoconference). They were evaluated three times: before the intervention, one week, and two months afterwards. This research also sought to evaluate the potency of the empty chair intervention for unfinished business with a complicated grief sample. This is another of the main contributions of this research. This task is mentioned by various authors for its ability to generate clinical change in complicated grief (Boelen et al., 2021; Bryant et al., 2014; Glickman et al., 2016; Holland et al., 2018). However, this task had not been studied yet in complicated grief. Significant clinical changes were found both at one week and at two months, being greater at two months, both in the successful sessions where the resolution of the empty chair task was accomplished (obtaining better results) and with the sessions in general, the latter analysis having an effect size of around d = 1, thus offering some evidence of this intervention in the telematic format (videoconference) and in complicated grief. Finally, we can say that the Existential Need Processing Model in Emotion-Focused Therapy predicts change in clinical outcomes. The more advanced the components are (e.g., Differentiated Relational Existential Need Expressed), the more consistent this prediction of clinical change is and the greater its presence in successful sessions and its relationship to the resolution of the empty chair task, thus confirming our hypothesis. We have also observed a certain sequentiality which indicates a progressive differentiation and expression in the relational need that, when achieved, is consistently more related to change.
La inteligencia emocional (IE) se refiere a la capacidad que tienen las personas de regular, controlar y adaptar sus emociones, así como la atención empleada para conocer y comprender los sentimientos de uno mismo y del otro. Mientras que el duelo complicado (DC) es una variante del duelo normal, se presenta cuando las personas atraviesan el fallecimiento de un ser querido. Este tipo de duelo no se mitiga a lo largo del tiempo y la intensidad de sus síntomas va en aumento. El objetivo de la investigación es determinar la relación que existe entre las dimensiones de IE y las dimensiones de DC en adultos. El estudio fue realizado a 90 estudiantes mayores de edad de una Unidad Educativa de Ecuador en la provincia de Tungurahua, los cuales han perdido por fallecimiento a un ser querido hasta hace 8 años. Como instrumentos de estudio se utilizó la Escala Rasgo de Metaconocimientos sobre Estados Emocionales (TMMS-24) y el Inventario de Factores Vitales que Interfieren en el Duelo y Duelo Complicado - versión 2 (ILFIGv2). Los resultados obtenidos evidencian que existe una correlación positiva leve entre las dimensiones de IE y DC demostradas mediante la prueba de Spearman, la cual señala que hay entre un 95% (p<0.05) a un 99% (p<0.001) de confianza en casi todas las dimensiones.
Background: Prolonged grief disorder (PGD) has been included in the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders 5 Text Revision (DSM-5-TR). Loss-related avoidance behavior perpetuates grief and effective interventions for prolonged grief symptoms target such avoidance behavior. Yet, behaviors characterized by approach of loss-related cues (i.e. rumination, yearning, proximity seeking) are also implicated in prolonged grief reactions.
Objective: To solve this paradox, we will test the Approach Avoidance Processing Hypothesis, which holds that loss-related approach and avoidance behaviors co-occur in PGD, using latent class analyses (LCA).
Methods: Two-hundred eighty-eight bereaved adults (92% female) completed questionnaires assessing loss-related approach behaviors (rumination, yearning, proximity seeking), loss-related avoidance behaviors (anxious avoidance, experiential avoidance) and ICD-11 and DSM-5-TR prolonged grief symptoms.
Results: LCA demonstrated the best fit for a three-class solution comprising a low approach/low avoidance class (n = 98, 34%), a high approach/low avoidance class (n = 79, 27%), and a high approach/high avoidance class (n = 111, 39%). The latter class showed significantly higher prolonged grief symptom levels and higher odds of probable PGD compared to the other classes.
Conclusions: Co-occurrence of loss-related approach and avoidance appears characteristic to prolonged grief reactions. Distinguishing bereaved people with these behavioral patterns from those solely experiencing loss-related approach behaviors may improve the efficacy of PGD therapies.
Thirty-nine bereaved individuals completed the Continuing Bonds Scale (CBS), assessing various aspects of the ongoing attachment to the deceased, at 60 months postloss in a longitudinal conjugal bereavement study. They also completed symptom measures at 6, 14, 25, and 60 months postloss. Higher CBS scores were associated with a more elevated grief-specific symptom pattern over the 5-year postloss period. Moreover, those who expressed greater helplessness and less blame toward the deceased during a monologue role-play involving their deceased spouse at 6 months postloss had higher CBS scores. Finally, greater satisfaction in the past relationship with the spouse was predictive of higher CBS scores. The results were discussed in relation to existing literature on the adaptiveness of continuing bonds.
Persistent complex bereavement disorder (PCBD) is a disorder of grief included in DSM-5. Prolonged grief disorder (PGD) is included in ICD-11. Few studies have evaluated and compared criteria-sets for DSM-5 PCBD and ICD-11 PGD. The current study explored and compared the dimensionality, prevalence rates, diagnostic agreement, concurrent validity, and socio-demographic and loss-related correlates of both criteria-sets. Self-reported data were available from 551 bereaved individuals. Confirmatory factor analysis showed that for DSM-5 PCBD-symptoms, a three-factor model with distinct but correlated factors fit the data well; for ICD-11 PGD-symptoms a one-factor model yielded adequate fit. The prevalence of probable DSM-5 PCBD (8.2%) was significantly lower than ICD-11 PGD (19.2%). Both DSM-5 PCBD and ICD-11 PGD were significantly associated with concurrent overall grief and depression, and varied as a function of education and time since loss. ICD-11 PGD prevalence-rates went down and agreement with PCBD-caseness went up, when heightening the number of symptoms required for a ICD-11 PGD diagnosis. This study was limited by its reliance on self-reported data and grief-symptoms were derived from two scales. That notwithstanding, findings provide further evidence that differences exist between disturbed grief criteria in DSM-5 and ICD-11 that may negatively impact research and care.
Given the severe mental health consequences that may ensue after bereavement it is crucial to better understand malleable cognitive factors that are associated with poorer bereavement outcomes. Grief rumination (i.e. repetitive thinking about the causes and consequences of a loss) is a malleable cognitive process that is concurrently and longitudinally associated with post‐loss mental health problems. To assess grief rumination, the English and Dutch Utrecht Grief Rumination Scale (UGRS) were recently developed. The current study examined the reliability and validity of a Chinese version of the UGRS. Three hundred and ninety‐three Chinese adults (56% women) bereaved on average 16.88 months ago filled out online questionnaires assessing demographic and loss‐related characteristics, grief rumination (UGRS), trait rumination, trait mindfulness, and anxiety, depressive, and prolonged grief symptoms. Confirmatory factor analyses showed that a second‐order five‐factor hierarchical model provided the most optimal factor structure for the Chinese UGRS. UGRS scale and subscale scores demonstrated acceptable internal consistency. Grief rumination had a moderate positive association with trait rumination and a low negative association with trait mindfulness, providing convergent and discriminant validity evidence. Test‐criterion validity evidence was also provided. UGRS scores could distinguish bereaved groups with different relationships with the deceased. Moreover, grief rumination was associated with symptoms of anxiety, depression, and prolonged grief even after controlling for demographic and loss‐related variables, trait rumination, and trait mindfulness. The Chinese UGRS appears a valid and reliable instrument to assess grief rumination in Chinese bereaved individuals.
This study aimed to validate the Swedish version of the Prolonged Grief Disorder-13 tool (PG-13) by examining its psychometric properties, including factor structure, discriminant and concurrent validity. The PG-13 was assessed in a sample of Swedish parents who had lost a child to cancer 1-5 years previously. The sample included 225 parents (133 mothers and 92 fathers) with a mean age of 46.02 years (SD = 8.15) and 16.0% met the criteria for Prolonged Grief Disorder (PGD). A principal component analysis was performed, and the results supported a one-factor structure of the PG-13. The PG-13 was shown to have high internal consistency and intelligible associations with concurrent psychological symptoms and grief rumination as well as with known risk factors for PGD. These results indicate satisfactory psychometric properties of the instrument, thus supporting the use of the PG-13 as a valid measure of PGD.
Background:
Bereavement can result in severe mental health problems, including persistent, severe and disabling grief symptoms, termed complicated grief. Grief rumination (i.e., repetitive thought about the causes and consequences of the loss) is a malleable cognitive risk-factor in adjustment to bereavement. The Utrecht Grief Rumination Scale (UGRS) was recently developed to assess grief rumination. The present study aimed to develop and validate a German version of the UGRS.
Methods:
An online survey including measures of demographic and loss-related variables, grief rumination (UGRS), depressive rumination (brooding and reflection), and symptoms of depression, anxiety, and complicated grief, was administered online among 159 persons (87% women) who had lost a first-degree relative in the past three years. UGRS item analyses, a confirmatory factor analysis and associations of grief rumination with brooding, reflection and symptom levels were performed.
Results:
The internal consistency of the UGRS was good. The confirmatory factor analysis obtained a good fit for a model with five correlated grief rumination subscales. The UGRS contributed uniquely to the prediction of complicated grief symptoms even when controlling for symptoms of anxiety and depression, brooding, reflection, and demographic and loss-related variables. Discriminant validity of the UGRS was demonstrated by the fact that higher UGRS scores were found in participants with a higher likelihood of receiving a diagnosis of complicated grief (d > 1.60).
Conclusion:
The translated UGRS showed very good psychometric properties and the correlations with maladaptive ruminative styles and complicated grief symptoms demonstrated the clinical relevance of grief rumination. Limitations concerning generalisability of the results are discussed.
Adaptive regulation of positive and negative affect following the loss of a loved one may foster recovery. In two studies, using similar methods but different samples, we explored the association between positive (i.e., dampening and enhancing) and negative (i.e., rumination) affect regulation strategies and symptoms levels of post-loss psychopathology. Study 1 used data from 187 people confronted with the death of a loved one. In Study 2, the sample consisted of 134 relatives of long-term missing persons. Participants completed self-reports tapping prolonged grief, depression, posttraumatic stress symptoms, and affect regulation strategies. Hierarchical regression analyses showed that both negative and positive affect regulation strategies explained significant amounts of variance symptom-levels in both samples. In line with previous work, our results suggest that negative and positive affect regulation strategies relate to post-loss psychopathology. Future research should explore how both affect regulation strategies may adequately be addressed in treatment.
Background: Attentional bias refers to a preference for (e.g., vigilance) or a shifting away (e.g., avoidance) of one’s focus with respect to specific stimuli. Accumulating evidence suggests that an attentional bias toward death/threat-related stimuli exists in bereaved individuals experiencing prolonged grief (PG). Measuring for different processing may reflect different cognitive characteristics. Therefore, this study sought to compare information-processing biases in Chinese individuals with high versus low levels of PG symptomatology at supraliminal and subliminal levels, respectively.
Method: A 2 (grief level) × 2 (consciousness level) × 2 (word type) three-factor mixed design with supraliminal and subliminal tasks was utilized in the current study. Based on their Prolonged Grief Questionnaire-13 (PG-13) scores, 38 participants were included in the low-PG group, and 34 individuals were included in the high-PG group. All the participants completed a dot-probe task in which they were primed with death-related and life-related words paired with neutral stimuli.
Results: High-PG individuals were slower in reacting to the death-related information in both supraliminal and subliminal tasks. After controlling for other symptoms in the backward deletion regression, PG-13 scores significantly predicted the avoidance tendency to death-related words in the supraliminal task, while anxiety was the best predictor of turning one’s vision away from death-related stimuli in the subliminal trials.
Conclusion: The results suggested that high PG is associated with a tendency to avoid death-related words. Future research is needed to explore interventions that address the avoidance of death-related stimuli among individuals with elevated, or diagnosable, levels of PG.
This contribution provides an overview of rumination (i.e., thinking repetitively and recurrently about negative events and/or negative emotions) in adjustment to bereavement. First, we summarise a growing literature on rumination and mental health outcomes of bereavement. Next, we compare two main theories explaining the maladaptive effects of rumination after loss, which hold conflicting implications for clinical practice. The Response Styles Theory (RST) states that rumination is a maladaptive confrontation strategy that perpetuates distress by increasing negative cognitions, impairing problem solving and instrumental behaviour and reducing social support. Conversely, the Rumination as Avoidance Hypothesis (RAH) holds that rumination may serve to avoid painful aspects of the loss, thereby hampering adjustment to bereavement. Crucially, while RST predicts that distraction reduces rumination, RAH predicts that loss exposure is more effective. We review evidence for RST and RAH and their clinical implications and conclude with a brief exploration of ways to reconcile these theories.
Emotion regulation has been examined extensively with regard to important outcomes, including psychological and physical health. However, the literature includes many different emotion regulation strategies but little examination of how they relate to one another, making it difficult to interpret and synthesize findings. The goal of this meta-analysis was to examine the underlying structure of common emotion regulation strategies (i.e., acceptance, behavioral avoidance, distraction, experiential avoidance, expressive suppression, mindfulness, problem solving, reappraisal, rumination, worry), and to evaluate this structure in light of theoretical models of emotion regulation. We also examined how distress tolerance—an important emotion regulation ability —relates to strategy use. We conducted meta-analyses estimating the correlations between emotion regulation strategies (based on 331 samples and 670 effect sizes), as well as between distress tolerance and strategies. The resulting meta-analytic correlation matrix was submitted to confirmatory and exploratory factor analyses. None of the confirmatory models, based on prior theory, was an acceptable fit to the data. Exploratory factor analysis suggested that 3 underlying factors best characterized these data. Two factors—labeled Disengagement and Aversive Cognitive Perseveration—emerged as strongly correlated but distinct factors, with the latter consisting of putatively maladaptive strategies. The third factor, Adaptive Engagement, was a less unified factor and weakly related to the other 2 factors. Distress tolerance was most closely associated with low levels of repetitive negative thought and experiential avoidance, and high levels of acceptance and mindfulness. We discuss the theoretical implications of these findings and applications to emotion regulation assessment.
Background and objectives:
Repetitive thought is a trans-diagnostic risk factor for development of psychopathology. Research on repetitive thought in bereaved individuals has focused primarily on clarifying the role of rumination, repetitive thinking about past negative events and/or negative emotions. While detrimental effects of rumination have been demonstrated following bereavement, surprisingly few studies have aimed to clarify the role of worry, repetitive thinking about potential future negative events, in adjustment to loss. This study sought to fill this gap in knowledge.
Methods/design:
183 bereaved individuals (85.3% women) filled out questionnaires on sociodemographic and loss-related characteristics, worry, and symptom measures of depression, anxiety, and prolonged grief. After six months, 155 participants completed worry and symptom measures again. Using multiple regression analyses, concurrent and longitudinal associations between loss-related variables, worry, and symptoms of psychopathology were examined.
Results:
Main results were that worry was strongly positively associated with symptoms of anxiety, depression and prolonged grief concurrently and also predicted higher levels of anxiety, depression and prolonged grief longitudinally.
Conclusions:
Findings suggest that worry influences adjustment to bereavement negatively and may be a potential target in grief therapy, especially when aiming to reduce anxiety.
Purpose of review:
There is increasing recognition that a minority of bereaved persons experiences persistent and disabling grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment research within a cognitive behavioral treatment framework, and establish a novel and systematic research agenda for complicated grief treatment.
Recent findings:
Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to definitions of complicated grief may threaten generalizability and clinical application of research findings. Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in targeting complicated grief. However, little is known about what, how, and for whom treatment works best.
Summary:
In light of these findings, we recommend systematic investigation of: what works best in complicated grief treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling studies; how it works, by conducting investigations on therapeutic theories and examining mediators of therapeutic change; and for whom it works, by examining potential moderators of treatment effects.
Suicide bereavement and complicated grief: Experiential avoidance as a mediating mechanism. In the wake of increased interest in the specific features of suicide bereavement, the current study examines (1) the association between suicide bereavement and complicated grief and (2) the mediating effect of experiential avoidance on the association between suicide bereavement and complicated grief. The tests revealed a significant indirect effect of suicide bereavement on complicated grief through experiential avoidance. This finding suggests that traumatic characteristics of suicide bereavement may inhibit the grieving process by increasing experiential avoidance and emphasizing a cognitive approach for complicated grief of people who lost their loved one to death by suicide.
Research has shown that violent losses lead to more severe emotional distress than do nonviolent losses. Little is known about the psychological mechanisms underlying the debilitating impact of violent loss. In the current study, the authors used self-reported data of 496 bereaved individuals, bereaved in the last 3 years, to examine the role of seven cognitive-behavioral variables in mediating the impact of violent loss: (a) a sense of "unrealness" about the irreversibility of the separation, negative cognitions about (b) the self, (c) life, (d) the future, and (e) catastrophic misinterpretations of grief-reactions, and indices of (f) anxious avoidance and (g) depressive avoidance behavior. Outcomes showed that people bereaved by violent losses (due to homicide, suicide, or accident) had significantly higher symptom-levels of Prolonged Grief Disorder (PGD), posttraumatic stress disorder (PTSD), and depression than persons bereaved by nonviolent losses. Indices of unrealness, negative cognitions about the self, the future, catastrophic misinterpretations, and depressive avoidance were all significant independent mediators of the linkages between violent loss and symptom-levels of PGD and depression. Negative cognitions about the future, catastrophic misinterpretations, and depressive and anxious avoidance emerged as unique mediators of the association between violent loss and elevated PTSD severity. Findings underscore that cognitive-behavioral variables are a critical component of elevated emotional distress following violent loss. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
This study examined the effectiveness and feasibility of therapist-guided internet-delivered exposure (EX) and behavioral activation (BA) for complicated grief and rumination. Forty-seven bereaved individuals with elevated levels of complicated grief and grief rumination were randomly assigned to three conditions: EX (N = 18), BA (N = 17), or a waiting-list (N = 12). Treatment groups received 6 homework assignments over 6-8 weeks. Intention-to-treat analyses showed that EX reduced complicated grief, posttraumatic stress, depression, grief rumination and brooding levels relative to the control group at post-treatment (d = 0.7-1.2). BA lowered complicated grief, posttraumatic stress and grief rumination levels at post-treatment (d = 0.8-0.9). At 3 month follow-up, effects of EX were maintained on complicated grief and grief rumination (d = 0.6-1.2), and for BA on complicated grief, posttraumatic stress and grief rumination (d = 0.8-0.9). EX reduced depression more strongly than BA (d = 0.6). Completers analyses corroborated results for EX, and partially those for BA, but no group differences were detected. BA suffered from high dropout (59%), relative to EX (33%) and the waiting-list (17%). Feasibility appeared higher for EX than BA. Results supported potential applicability of online exposure but not behavioral activation to decrease complicated grief and rumination.
Coping strategies play a significant role in overall adjustment to bereavement, and recent emphasis has been placed on flexibility in coping versus unilateral strategies that are seemingly beneficial or maladaptive. The Dual Process Model of coping informed the conceptualisation of coping flexibility as the oscillation between ‘trauma focus’ and ‘forward focus’ coping strategies. The primary aim of the present study was to assess whether trauma focus and forward focus coping strategies, and using strategies from both flexibly, would predict grief severity. Trauma focus and forward focus were assessed using the Perceived Ability to Cope with Trauma (PACT) scale, measured cross-sectionally in older widows and widowers. In addition, we modeled symptoms of loneliness, yearning and perceived stress from PACT scale scores. Results showed that greater forward focus and coping flexibility predicted lower grief severity, and also predicted lower yearning, loneliness, and perceived stress. Additionally, length of time that participants were bereaved moderated the relationships of forward focus coping and coping flexibility to grief symptoms, such that having greater forward focused coping and coping flexibility matter the most early in bereavement.
People respond to stressful events in different ways, depending on the event and on the regulatory strategies they choose. Coping and emotion regulation theorists have proposed dynamic models in which these two factors, the person and the situation, interact over time to inform adaptation. In practice, however, researchers have tended to assume that particular regulatory strategies are consistently beneficial or maladaptive. We label this assumption the fallacy of uniform efficacy and contrast it with findings from a number of related literatures that have suggested the emergence of a broader but as yet poorly defined construct that we refer to as regulatory flexibility. In this review, we articulate this broader construct and define both its features and limitations. Specifically, we propose a heuristic individual differences framework and review research on three sequential components of flexibility for which propensities and abilities vary: sensitivity to context, availability of a diverse repertoire of regulatory strategies, and responsiveness to feedback. We consider the methodological limitations of research on each component, review questions that future research on flexibility might address, and consider how the components might relate to each other and to broader conceptualizations about stability and change across persons and situations.
© The Author(s) 2013.
The aim of the study is to identify the mediators of complicated grief in a Portuguese sample of caregivers. Grief mediators were prospectively evaluated using a list of risk factors completed by the palliative care team members, during the predeath and bereavement period. More than 6 months after the death, we applied PG-13 to diagnose prolonged grief disorder (PGD). The sample was composed of 64 family caregivers. Factors associated with PGD were insecure and dependent relationship, unresolved family crisis, and the perceived deterioration and disfigurement of the patient. The results show relational factors are relevant, but we must consider the reciprocal influence among factors, as well as their impact on specific symptoms.
© The Author(s) 2015.
Background:
Avoidance behavior is a central component of cognitive behavioral theories of bereavement-related psychopathology. Yet, its role is still not well understood. This study examined associations of anxious and depressive avoidance behaviors with concurrently and prospectively assessed symptom-levels of prolonged grief disorder (PGD), depression, and posttraumatic stress disorder (PTSD).
Design and methods:
Two hundred and ninety-one individuals, confronted with loss maximally three years earlier, completed self-report measures of anxious and depressive avoidance and emotional distress and again completed distress measures one year later.
Results:
Anxious and depressive avoidance were concurrently associated with symptom-levels of PGD, depression, and PTSD, even when controlling for the shared variance between both forms of avoidance and relevant socio-demographic and loss-related variables. Prospective analyses showed that baseline anxious avoidance predicted increased symptom-levels of PGD, depression, and PTSD one year later, among participants who were in their first year of bereavement but not among those who were beyond this first year. Baseline depressive avoidance was significantly associated with elevated PTSD one year later, irrespective of time since loss.
Conclusions:
Both anxious and depressive avoidance are associated with different indices of poor long-term adjustment following loss. However, anxious avoidance seems primarily detrimental in the first year of bereavement.
Recurring rumination is strongly associated with grief reactions severity. In this study, we examined whether deficits in cognitive inhibition were related to such a dysfunctional process. Inhibition was investigated among low and high bereaved ruminators in a negative affective priming task with grief-related, negative and positive words. Results revealed impaired inhibition for grief-related information in comparison with negative and positive information in bereaved individuals with elevated rumination. When accounting for differences in grief reactions, the present findings did not however confirm the hypothesis of a direct link between variations in inhibition performances and rumination. Implications for future research and clinical perspectives are discussed.
Rumination, a risk factor in adjustment to bereavement, has often been considered a confrontation process. However, building on research on worry in generalized anxiety disorder (GAD) and rumination in post-traumatic stress disorder (PTSD), researchers recently developed the Rumination as Avoidance Hypothesis (RAH), which states that rumination after bereavement serves to avoid the reality of the loss. In the present study, RAH was tested by investigating if rumination is associated with implicit loss avoidance.Methods
An Approach Avoidance Task (AAT) was used to assess automatic behavior tendencies. Using a joystick, 71 persons who recently lost a first-degree relative (90.1% women), pulled stimuli toward themselves or pushed them away from themselves. Stimuli represented the loss (picture deceased + loss word), were loss-related but ambiguous (picture deceased + neutral word; picture stranger + loss word), or were non-loss-related (picture stranger + neutral word; puzzle picture + X’s).ResultsParticipants who ruminated more were relatively faster in pushing loss stimuli away from themselves and slower in pulling loss stimuli towards themselves, implying more rumination was associated with stronger implicit loss avoidance. Effects were maintained after controlling for depressive or post-traumatic stress symptom levels, but not when controlling for prolonged grief symptom levels.LimitationsConjugally bereaved women were overrepresented in the sample, which limits generalizability of results. The study was correlational, precluding causal inferences.Conclusions
In line with RAH, rumination was positively associated with loss avoidance. This may indicate that the application of exposure-based techniques can reduce rumination and loss-related psychopathology.
Emotion regulation (ER) has been identified as a critical factor in the development and
maintenance of posttraumatic stress symptoms (PTS; Bardeen, Kumpula, & Orcutt, 2013 [Journal of
Anxiety Disorders, 27, 188–196]; Marx & Sloan, 2005 [Behaviour Research and Therapy, 43, 569–
583]; Nightingale & Williams, 2000 [British Journal of Clinical Psychology, 39, 243–254]). The current
meta-analysis aimed to provide a thorough, quantitative examination of the associations between
PTS and several aspects of ER. A search of the PsychINFO database resulted in 2557 titles, of which
57 met full inclusion criteria (the cross-sectional association between PTS symptoms and ER was
reported, participants were 18 years or older, the article was written in English, and sufficient
information was reported to calculate effect sizes). From the 57 studies that were included, 74 effect
sizes were obtained. All studies were independently coded by two of the study authors for the
following: citation, sample type, total N size (and group n’s if applicable), mean age of participants,
type of traumatic event, study design, PTS measure(s), ER measure(s), and effect size information.
Eight random effects models were conducted: seven for individual ER strategies (e.g., rumination)
and one for general emotion dysregulation. The largest effects were observed for general emotion
dysregulation (r ¼ 0.53; k ¼ 13), rumination (r ¼ 0.51; k ¼ 5), thought suppression (r ¼ 0.47;
k ¼ 13), and experiential avoidance (r ¼ 0.40; k ¼ 20). Medium effects were observed for expressive
suppression (r ¼ 0.29; k ¼ 3) and worry (r ¼ 0.28; k ¼ 6). Significant effects were not observed for
acceptance or reappraisal. Moderator analyses (sample and trauma type) were conducted for general
emotion dysregulation, experiential avoidance, and thought suppression; no significant differences
were observed. Findings from the current analysis suggest that several aspects of ER are associated
with PTS symptoms across a variety of samples. Additionally, the current study highlights a number
of limitations in the existing ER and PTS symptom literature. Key words: emotion regulation; PTSD;
trauma; meta-analysis.
Objectives
Rumination is a risk factor after bereavement, predicting higher concurrent and prospective symptom levels of complicated grief and depression in mourners. Research has shown that rumination may consist of adaptive and maladaptive subtypes, but there has been a paucity of research in this topic in the bereavement area. Therefore, we aimed to clarify whether functional and dysfunctional forms of rumination can be distinguished after loss. DesignTwo-hundred and forty-two adults, who lost a first-degree family member on average 10months previously, filled out questionnaires at three time points with 6months between each time point. Methods
Multiple regression analyses, controlled for loss-related variables, neuroticism, and baseline symptoms, were run to examine associations of subtypes of depressive rumination (brooding, reflection) and grief rumination (rumination about injustice, meaning, reactions, relationships and counterfactual thinking) with concurrent and prospective symptom levels of complicated grief and depression. ResultsOverall, grief rumination explained more variance in symptom levels than depressive rumination. Other major findings were that grief rumination about injustice predicted higher concurrent and prospective symptom levels of complicated grief and higher prospective symptom levels of depression. In contrast, grief rumination about emotional reactions was related to prospective reductions in symptoms of complicated grief. Reflection was also associated with prospective reductions of complicated grief and depressive symptom levels. Conclusions
Results indicate that adaptive and maladaptive forms of ruminative thinking can be distinguished in bereaved individuals. Therapeutic interventions for complicated grief could potentially be improved by including techniques aimed at reducing maladaptive rumination and increasing adaptive rumination.
Rumination is a risk factor in adjustment to bereavement. It is associated with and predicts psychopathology after loss. Yet, the function of rumination in bereavement remains unclear. In the past, researchers often assumed rumination to be a maladaptive confrontation process. However, based on cognitive avoidance theories of worry in generalised anxiety disorder (GAD) and rumination after post-traumatic stress disorder (PTSD), others have suggested that rumination may serve to avoid painful aspects of the loss, thereby contributing to complicated grief. To examine if rumination is linked with loss avoidance, an eye-tracking study was conducted with 54 bereaved individuals (27 high and 27 low ruminators). On 24 trials, participants looked for 10 seconds at a picture of the deceased and a picture of a stranger, randomly combined with negative, neutral or loss-related words. High ruminators were expected to show initial vigilance followed by subsequent disengagement for loss stimuli (i.e., picture deceased with a loss word) in the first 1500 ms. Additionally, we expected high ruminators to avoid these loss stimuli and to show attentional preference for non-loss-related negative stimuli (i.e., picture stranger with a negative word) on longer exposure durations (1500–10000 ms). Contrary to expectations, we found no evidence for an effect of rumination on vigilance and disengagement of loss stimuli in the first 1500 ms. However, in the 1500–10000 ms interval, high ruminators showed shorter gaze times for loss stimuli and longer gaze times for negative (and neutral) non-loss-related stimuli, even when controlling for depression and complicated grief symptom levels. Effects of rumination on average fixation times mirrored these findings. This suggests that rumination and loss avoidance are closely associated. A potential clinical implication is that rumination and grief complications after bereavement may be reduced through the use of exposure and acceptance-based therapeutic techniques.
: Accumulating evidence supports behavioral activation (BA) as an effective stand-alone treatment for improving depression and related conditions, though little is known about the factors that influence positive outcomes. Such research is ripe for future dissemination and implementation efforts, particularly among vulnerable older adult populations in need of such efficacious and transportable treatments.
Aims
: Given the central but largely unexamined role that increasing activities plays in BA, we investigated the association between participation in weekly activities and treatment outcome.
Method
: As a preliminary study of this research question, we report on a sample of 20 older adults with symptoms of depression and complicated bereavement who completed 5 weeks of BA, pre- and posttreatment measures, and weekly planners of BA activities. All activities were coded as either functional or pleasurable (by participants) and if they were social in nature (by trained coders).
Results
: Overall, BA was associated with reductions in symptomatology. However, participants’ total number of reported activities, and their relative proportion of functional, pleasurable, and social activities, did not significantly relate to their improvement in symptoms.
Conclusion
: One interpretation of the findings suggests that countering avoidance more generally, potentially independent of the specific type or total amount of activation activities, may be associated with amelioration of symptomatology.
Two different types of ruminative coping, depressive rumination and grief rumination, negatively influence bereavement outcome. Although grief-specific rumination is likely to be relevant in the bereavement context no internationally validated scale to measure grief rumination exists. Therefore, the current contribution aims to validate the Utrecht Grief Rumination Scale (UGRS), a scale developed to measure grief-specific rumination, in an English sample. Psychometric properties of the English UGRS were compared with those in a Dutch sample. 204 British adults (89 % women, 11 % men), bereaved on average 16 months ago, and 316 Dutch adults (88 % women, 12 % men), bereaved on average 12 months ago, filled out online questionnaires. Different types of rumination (grief rumination, brooding, reflection, trait rumination) and symptoms of psychopathology (anxiety, depression, complicated grief) were measured. A correlated five factor model provided the best fit for the UGRS. Multi-group comparisons showed that the factor structures of the English and Dutch version of the UGRS were highly similar across language groups. The UGRS showed excellent reliability. Results further supported the construct, convergent, divergent and concurrent validity of the English UGRS. The psychometric properties of the Dutch UGRS corroborated these findings. The UGRS appears a valid instrument to assess grief-specific rumination in international research and may have potential applicability as a clinical instrument to assess rumination in individuals with problematic grief
Ruminative coping has been associated with negative outcomes in bereavement. Rather than assuming it to be a problematic confrontation process, researchers have recently suggested rumination to be maladaptive through its links with avoidance processes. The main aim of this study was to examine, for the first time, whether the relationship between ruminative coping and symptoms of complicated grief and depression is mediated by avoidance processes (suppression, memory/experiential avoidance, behavioral avoidance, loss-reality avoidance). A sample of 282 adults (88% female, 12% male), bereaved on average 18 months previously, filled out three questionnaires at 6-month intervals. We assessed symptom levels, grief rumination, and trait rumination at baseline; avoidance processes after 6 months; and symptom levels after 12 months. When controlling for initial symptom levels, experiential avoidance mediated the link between grief rumination and complicated grief, and experiential avoidance and behavioral avoidance mediated the link between grief rumination and depression. Post hoc analyses showed suppression may also mediate the link between grief rumination and symptoms of complicated grief, but not depression. Loss-reality avoidance was no significant mediator of these relationships. This study provides initial evidence that rumination during bereavement increases and perpetuates symptoms of psychopathology, because it is linked with specific avoidance processes. Bereaved individuals with problematic grief and (chronic) rumination may benefit from therapy focused on countering avoidance tendencies. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
According to the Dual Process Model of coping with bereavement (DPM; Stroebe & Schut, 1999), adjustment to bereavement involves a flexible oscillation between two types of coping strategies: loss-oriented (LO) and restoration-oriented (RO). This model postulates that extremely anxious or avoidant attachment disturbs the oscillation process by focusing more on one type of strategy, either LO or RO. The present study examined this assumption. We recruited 321 bereaved individuals who had lost a romantic partner. Our results showed that less negative appraisal of bereavement-related stressors, as well as higher use of RO strategies, mediated the link between attachment avoidance and low severity of grief reactions. However, the DPM variables were not found to mediate the link between attachment anxiety and elevated grief reactions. We discuss how these results provide an empirical basis of the DPM.
The present study aims to explore the factors which are associated with grief and depression outcomes in a group of bereaved parents in the first few years following the loss of a child. Sixty-four participants were recruited from bereavement support organisations, between two and 59 months post loss, mean 30 months (SD = 15). They completed a questionnaire packet which comprised standard instruments measuring grief, depression, coping styles, continuing bonds and optimism/pessimism, as well as a number of specific bereavement-related questions. Univariate analyses were conducted to establish which factors were associated with grief and depression. Those which were statistically significant were then entered into multivariate analyses to establish their relative importance. High levels of avoidance and depression and lower levels of cognitive restructuring (benefit finding) were associated with higher grief symptoms, whereas higher levels of avoidance and alcohol/substance use were associated with higher depression symptoms. The present study highlights the relative importance of different coping strategies adopted by this group of bereaved parents, compared to the relative unimportance of circumstances around the loss, e.g. sudden or violent death. The use of alcohol and other substances by bereaved parents requires urgent attention as a potentially life-threatening maladaptive coping strategy. The call for further research into risk factors for bereaved parents is emphasised.
Objectives:
Across many research domains, evidence for complicated grief as a distinct psychopathology continues to grow. Previous research from neuropsychology has shown an increased attentional bias to emotionally relevant stimuli in those suffering from complicated grief. This study furthers our understanding of the characteristics that distinguish complicated grief. We expand on previous research by (a) testing older adults, (b) excluding those with comorbid major depressive disorder, (c) using participant-chosen grief-related stimuli, and (d) using a married, nonbereaved control group.
Methods:
We recruited 76 older adults in 3 groups: spousally bereaved with complicated grief, spousally bereaved with noncomplicated grief, and nonbereaved controls. Performance on the Wisconsin Card Sorting Task, Digit Span Backwards, and the emotional counting Stroop was examined.
Results:
Results indicate longer reaction time across 3 blocks of grief-related words in the complicated grief group but no difference across 3 blocks of the neutral words. The 3 groups performed comparably on the other neurocognitive tasks, indicating no cognitive differences in working memory or set shifting between groups. Furthermore, these effects of complicated grief generalize to older adults and appear independent of major depression.
Discussion:
Complicated grief has cognitive interference as a neuropsychological component highlighting it as distinct from noncomplicated grief.
Following loss, people can develop symptoms of depression, Post-Traumatic Stress Disorder (PTSD), or Complicated Grief (CG) - also termed Prolonged Grief Disorder (PGD). A recent cognitive-behavioural model has proposed that avoiding confrontation with the reality of the loss (called “anxious avoidance” [AA]) and refraining from activities that could foster adjustment (called “depressive avoidance” [DA]) both play a critical role in CG/PGD. The present study examined this assumption, using self-reported data from 161 mourners. Findings showed that items constituting AA and DA represented two distinct factors. Both factors were strongly correlated with other measures of bereavement-related avoidance and both accounted for a unique part of the explained variance in CG/PGD severity, beyond relevant background variables, negative cognitions, and concomitant symptom-levels of depression and PTSD. DA also explained unique variance in depression beyond these variables. Moreover, AA and DA mediated the linkages of neuroticism, attachment anxiety, and attachment avoidance with symptom-levels of CG/PGD.
Theories about coping with potential trauma have emphasized the importance of concerted focus on processing the traumatic event. However, empirical evidence also suggests that it may be salubrious to distract oneself, remain optimistic, and focus on moving past the event. These seemingly contradictory perspectives are integrated in the concept of coping flexibility. This investigation reports the development and validation of a brief questionnaire, the Perceived Ability to Cope With Trauma (PACT) scale, with 2 scales that measure the perceived ability to focus on processing the trauma (trauma focus) and to focus on moving beyond the trauma (forward focus). In addition, we created a single flexibility score that represented the ability to use both types of coping. Participants included an Israeli sample with potential high trauma exposure and a sample of American college students. The factor structure of the PACT was confirmed in both samples. Preliminary evidence was obtained for the PACT's convergent, discriminant, and incremental validity. Both the Forward Focus and Trauma Focus scales were independently associated with better adjustment, and each scale independently moderated the impact of heightened trauma exposure. Similarly, the combination of these scales into a single parsimonious flexibility score also moderated trauma exposure. Limitations of and future research with the measure are considered. (PsycINFO Database Record (c) 2012 APA, all rights reserved)