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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.
... 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.
... Adaptation to bereavement requires effective strategies to manage these emotions. Therefore, emotion regulation is critical in the development and reduction of severe grief reactions (Eisma & Stroebe, 2021). Mental health problems that frequently co-occur with prolonged grief, such as depression, are also characterized by severe emotional disturbances (Komischke-Konnerup et al., 2021). ...
... Emotion regulation strategies are proposed to be either adaptive or maladaptive (Naragon-Gainey et al., 2017). A recent systematic review of empirical research on the relationships between emotion regulation strategies and prolonged grief symptoms has demonstrated that there is an overrepresentation of studies on putative maladaptive emotion regulation strategies, such as rumination or avoidance (Eisma & Stroebe, 2021). However, research aiming to elucidate the role of putative adaptive emotion regulation strategies in psychological adaptation to bereavement is scarce. ...
... Positive reappraisal is the cognitive process by which stressful situations are reconstrued as valuable or beneficial. Following bereavement, cognitive reappraisal may help to reinterpret negative experiences, including secondary stressors (Eisma & Stroebe, 2021), thereby decreasing associated emotional distress. A large survey in Nigeria found a small positive association between deliberate rumination (akin to positive reappraisal) and prolonged grief symptoms (Chukwuorji et al., 2018). ...
Background and Objectives
Maladaptive emotion regulation strategies increase prolonged grief and depressive symptoms following bereavement. However, less is known about the role of adaptive emotion regulation strategies in adaptation to loss. Therefore, we examined the concurrent and longitudinal associations of three putative adaptive emotion regulation strategies (cognitive reappraisal, emotional expression, and mindfulness) with prolonged grief and depression symptoms.
Design
A two-wave longitudinal survey.
Methods
A sample of 397 bereaved Dutch adults (89% female, mean age 54 years) completed validated questionnaires to assess trait cognitive reappraisal, emotional expression, mindfulness and prolonged grief and depression symptoms at baseline (T1) and 344 participants completed symptom measures again six months later (T2).
Results
Zero-order correlations demonstrated that mindfulness, cognitive reappraisal and emotional expression relate negatively to T1 and T2 prolonged grief and depression symptoms. In multiple regression analyses, controlling for relevant background variables, all emotion regulation strategies related negatively to T1 prolonged grief and depression symptoms. In multiple regression analyses, controlling for T1 symptoms and background variables, mindfulness predicted lower T2 depression symptoms.
Conclusions
Adaptive emotion regulation strategies relate negatively to post-loss psychopathology symptoms, yet only mindfulness longitudinally predicts lower depression symptoms. Dispositional mindfulness may be a protective factor in psychological adaptation to bereavement.
... Knowledge on changeable determinants of psychological outcomes of bereavement may help improve treatments for distressed bereaved people. Accordingly, grief researchers have aimed to clarify these determinants (for a review: Eisma & Stroebe, 2021). ...
... Most commonly, it is conceptualized as worry (predominantly verbal repetitive thought about uncertain future events with potential negative outcomes; Borkovec et al., 1998) or depressive rumination (repetitively and passively focusing on the nature, causes, and consequences of one's low mood; Nolen-Hoeksema et al., 2008). These cognitive processes relate to mood and anxiety disorders, such as depression and generalized anxiety disorder, as well as stress-related disorders, including PTSD and PGD (Eisma & Stroebe, 2021;Moulds et al., 2020;Nolen-Hoeksema et al., 2008;Olatunji et al., 2013). Systematic reviews and metaanalyses have demonstrated that treatments targeting worry and rumination are effective in reducing psychopathology (e.g., Querstret & Cropley, 2013) and pilot randomized controlled trials demonstrate that such treatments may also reduce loss-related psychopathology (e.g., Eisma et al., 2015;Wenn et al., 2018). ...
... After loss, longing for, but not being able to obtain closeness to the lost person is the most salient discrepancy. Consequently, people will ruminate about the events leading up to the death and the consequences of bereavement (e.g., Davis et al., 1995;Eisma et al., 2021). ...
Bereavement can precipitate symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder. Targeting repetitive negative thought (i.e., worry, rumination) in treatment may help reduce post-loss psychopathology. Yet, evidence on longitudinal associations of depressive rumination and worry with post-loss psychopathology symptoms has been mixed and the directions of effects are still unclear. Recently bereaved adults (78% female), completed questionnaires assessing depressive rumination (brooding), worry, and depression, prolonged grief and posttraumatic stress symptoms 11 times in 1.5 month intervals. We applied random-intercept cross-lagged panel models (RICLPMs) to examine reciprocal within-person associations between worry and psychopathology symptoms, between rumination and these symptoms, and between worry and rumination. Main findings were that worry showed reciprocal relationships with psychopathology symptoms (although worry did not consistently predict prolonged grief symptoms). Depressive rumination was predicted by psychopathology symptoms, but not vice versa. Worry showed reciprocal relations with depressive rumination. Findings suggest that worry may be part of a downward spiral, enhancing psychopathology symptoms following loss, whereas depressive rumination is solely a consequence of such symptoms.
... Additionally, rumination and worry are both concurrently and longitudinally associated with post-loss psychopathology, including PG symptoms (e.g., Boelen, 2010;Morina, 2011;Nolen-Hoeksema et al., 1994, Nolen-Hoeksema et al., 1997: for a review, see Eisma & Stroebe, 2021). In a recent survey, both cognitive processes were uniquely concurrently associated with post-loss PG and depression symptoms, but rumination related more strongly to PG symptoms than worry did . ...
... Our hypotheses regarding the daily diary are based on prior work on rumination and NA in nonbereaved samples (Moberly & Watkins, 2008a, 2008b. However, since both worry and rumination are theoretically relevant to and linked with psychological adaptation to bereavement (Eisma & Stroebe, 2021) as well as affect (McLaughlin et al., 2007), we were more comprehensive in consideration of both the independent variables (including both trait and daily worry and rumination) and the dependent variables (including daily NA and PA). ...
... These findings are also consistent with contemporary (coping) models on grief, which hold that people who have trouble dealing effectively with loss-related emotions or who create fewer opportunities to experience positive mood are more likely to experience persistent mental health problems (e.g., Boelen et al., 2006;Shear et al., 2007;Stroebe & Schut, 1999). Correspondingly, improved emotion regulation is a central aim of many psychological interventions for severe grief reactions (Eisma & Stroebe, 2021;Johannsen et al., 2019). ...
After bereavement, a significant minority experiences severe, persistent, and disabling grief, termed prolonged grief or complicated grief. Prolonged grief treatments may be enhanced by improving understanding of malleable risk factors in post-loss psychological adaptation. Repetitive negative thought (e.g., rumination, worry) constitutes such a risk factor. Rumination and worry are both theorized to be maladaptive through interrelations with affect, yet this assumption has not been systematically investigated in the bereaved. We aimed to fill this gap in knowledge with a baseline
survey and 10-day daily diary investigation among a bereaved sample. Survey between-subject analyses (N = 113) demonstrated that trait rumination and worry, trait negative affect and prolonged grief symptoms are positively related to each other and negatively related with trait positive affect. Within-subject multilevel analyses of diaries (N = 62) demonstrated that trait rumination and trait worry relate positively to daily negative affect and negatively to daily positive affect. Daily rumination and worry showed similar relationships with daily negative and positive affect. A stronger relationship emerged between daily rumination and daily negative affect in people with higher prolonged grief symptom levels. Findings consistently support interrelations between repetitive negative thought, affect, and prolonged grief symptoms. Rumination appears particularly detrimental in people with severe grief reactions. Results align with research demonstrating the effectiveness of targeting
repetitive negative thought in prolonged grief treatments. Additionally, our study demonstrates the potential feasibility and usefulness of using daily diaries to study behaviours of relevance to post-loss adaptation in everyday life.
... Most of the prolonged grief research on emotion regulation has focused on the exploration of which emotion regulation and coping strategies are associated with prolonged grief symptoms (Boelen & van den Bout, 2010;Eisma et al., 2015;Robinson & Marwit, 2006). It has been found that rumination (Eisma et al., 2015, Eisma & Stroebe, 2020Lenferink et al., 2017;Morina, 2011) and experiential avoidance (Boelen & van den Bout, 2010;Eisma & Stroebe, 2020;Morina, 2011) were associated with increased risk for prolonged grief symptoms. ...
... Most of the prolonged grief research on emotion regulation has focused on the exploration of which emotion regulation and coping strategies are associated with prolonged grief symptoms (Boelen & van den Bout, 2010;Eisma et al., 2015;Robinson & Marwit, 2006). It has been found that rumination (Eisma et al., 2015, Eisma & Stroebe, 2020Lenferink et al., 2017;Morina, 2011) and experiential avoidance (Boelen & van den Bout, 2010;Eisma & Stroebe, 2020;Morina, 2011) were associated with increased risk for prolonged grief symptoms. ...
... We found that emotion regulation difficulties were associated with the severity of prolonged grief. Several theories and researchers of grief recognized that emotion regulation might play an important role in the development of prolonged grief (Boden et al. 2014;Eisma & Stroebe, 2020;Shear, 2012), but most of the previous studies analyzed the role of emotion regulation strategies (Boelen & van den Bout, 2010;Eisma & Stroebe, 2020;Lenferink et al., 2017). Adaptive emotion regulation involves several more processes that might affect the ways in which emotion regulation strategies are selected and implemented (Bonanno & Burton, 2013). ...
In this study, we aimed to test the mediating role of emotion regulation difficulties between prolonged grief disorder symptoms and three risk factors: neuroticism, avoidant attachment, and anxious attachment. A total sample of 203 bereaved participants was included in the study. Path analysis revealed that emotion regulation difficulties partly mediated the links between neuroticism, avoidant attachment, and prolonged grief symptoms, and mediated the link between anxious attachment and prolonged grief symptoms. The findings suggested that emotion regulation difficulties might be an important factor contributing to prolonged grief symptoms among bereaved individuals with high neuroticism and insecure attachment.
... 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.
... Within cognitive-behavioral models of prolonged grief, the construct of depressive avoidance (i.e., behavioral avoidance of social, occupational, and recreational activities) is considered to reflect an inability to engage in restoration-oriented coping (Boelen et al., 2006). Accordingly, depressive avoidance relates to more severe mental health outcomes concurrently and longitudinally (e.g., Boelen & Bout, 2013;; for a review: Eisma & Stroebe, 2021). Additionally, some authors have created lists of post-loss activities which may be indicative of restoration (e.g., visiting friends, engaging in hobbies, work) and found negative associations between engaging in such activities and wellbeing and prolonged grief symptoms (e.g., Monk et al., 2006;Stahl & Schulz, 2018;Richardson, 2006Richardson, , 2010. ...
... The results further suggest that appraisal of these stressors and worry may mediate this association. Results add to prior research showing that coping with restoration-oriented stressors relates to less severe grief (Fiore, 2019), and research showing that depressive avoidance of activities relates to more severe post-loss mental health problems (Eisma & Stroebe, 2021). It also complements trials showing that helping bereaved people deal with restoration-oriented stressors effectively, e.g., by engaging in new valued activities, reduces post-loss distress (e.g., Chow et al., 2018;Eisma et al., 2015). ...
Background and objectives
The Dual Process Model of Coping with Bereavement holds that bereaved people who respond flexibly to loss-oriented stressors (i.e., relating to the loss; to the deceased person) and restoration-oriented stressors (i.e., secondary to loss; daily-life changes, taking on new roles) adapt better to bereavement. Despite growing interest in the Dual Process Model, systematic analyses of the prevalence, characteristics, and correlates of restoration-oriented stressors are lacking. Therefore, we aimed to chart restoration-oriented stressors and their relationship with post-loss adaptation.
Design and methods
A community sample of 181 bereaved adults (63% women) completed the 20-item expert-construed Restoration-Oriented Stressors Inventory (ROSI) and questionnaires assessing background characteristics, worry, and prolonged grief and depression symptoms.
Results
Main findings were that younger people, and those who lost a parent, partner, or child (vs. other relationship) experienced more restoration-oriented stressors and appraised these as more stressful. Stressors’ perceived stressfulness, but not their quantity, related positively to worry. Perceived stressfulness predicted prolonged grief and depression symptoms beyond background characteristics, worry, and the number of stressors.
Conclusion
Restoration-oriented stressors and their appraisal vary and relate to coping and post-loss mental health. Future research should clarify temporal interrelations between stressors, coping mechanisms, and outcomes.
... Difficulties in emotion regulation has been found to be related to increased levels of negative affect and a range of psychological disorders (Aldao et al., 2010;Menin et al., 2007) including PTSD (Bradley et al., 2011) and complicated grief (for a review see Eisma & Stroebe, 2020), across a range of populations. Moreover, a recent study examining the relationship between IU and GAD found that about 31.4% of the total effect of IU in predicting the tendency to worry (the core feature of GAD) could be attributable to limited access to emotion regulation strategies (Ouellet et al., 2019). ...
... In the context of loss, research has largely focused on identifying specific regulatory processes that are associated with PGD symptomatology (e.g., rumination, avoidance; Eisma & Stroebe, 2020). Several theories of grief emphasize a key mechanism for healthy adjustment is the fluctuation between coping directed processes and avoidant coping processes (Boden et al., 2014;Stroebe et al., 2005). ...
When a loved one is missing, those left behind need to be able to tolerate high levels of uncertainty, sometimes for sustained periods of time. This study aimed to examine the relationship between intolerance of uncertainty (IU) and psychological symptoms among people with a missing loved one, and tested the mediating role of emotion regulation difficulties and psychological inflexibility. A cross-sectional sample of 110 people with a missing loved one completed a questionnaire containing demographics and measures of IU, difficulties in emotion regulation, psychological inflexibility and psychological symptoms. Results indicated that psychological inflexibility was a significant mediator of the associations between IU and psychological distress, prolonged grief and posttraumatic stress symptoms. Emotion regulation difficulties did not emerge as a significant mediator in any of the models. Findings suggest that stronger tendencies to respond negatively to uncertain situations are associated with increased attempts to avoid uncomfortable internal experiences (e.g., thoughts, feelings, memories or sensations) which, in turn, exacerbates psychological symptom levels. The findings have implications for developing interventions aimed at strengthening the ability to tolerate uncertainty and addressing psychological inflexibility among people with a missing loved one.
... 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 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 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).
... 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.
... Fase ini individu mulai dapat menerima peristiwa kehilangan yang dialami sehingga pikiran terhadap seseorang yang hilang tersebut mulai berkurang. Situasi emosi buruk berdampak munculnya kompensasi melalui penggunaan obat terlarang atau pergaulan bebas karena hilangnya kebutuhan kasih sayang, pendampingan yang baik (Akehurst & Scott, 2021;Brinkmann, 2018;Brinkmann & Kofod, 2018;Cesur-Soysal & Durak-Batıgün, 2020;Eisma & Stroebe, 2021;Huang et al., 2019;Jakoby, 2012, Papalia, 2008. Jika fase penerimaan tidak segera terkonsolidasi secara emosional, remaja beresiko terjebak pada situasi emosi terekspresi menjadi perilaku yang merugikan perkembangannya. ...
Remaja yang mampu bertumbuh paska trauma akibat duka mendalam ditinggal orang tua akan tetap punya potensi berkembang menjadi generasi yang sehat dan bebas dari kungkungan ketidaksehatan mental. Tulisan ini bertujuan mengungkap dinamika kebangkitan pasca trauma remaja yang begitu sulit setelah dilingkupi situasi duka mendalam karena kehilangan orang tua akibat kematian. Penelitian yang dilakukan menggunakan penelitian kualitatif studi fenomenologis. Partisipan penelitian seorang remaja yang telah ditinggal mati orang tuanya berusia 19 tahun. Pengumpulan data menggunakan teknik wawancara mendalam semi terstruktur. Analisis data dilakukan tematik grounded dengan beberapa tahap, yaitu transkripsi data, pemadatan fakta, kategorisasi, penarikan tema menjadi teori. Hasil penelitian menunjukkan proses grief (duka) remaja karena kematian orangtua memiliki beberapa tahapan pertumbuhan pasca kehilangan yaitu surplus parenting berdampak munculnya duka karena relasi emosional yang kuat, dukungan sosial emosional membangkitkan paska duka menjadikan seorang remaja percaya akan kehilangan yang tidak terelakkan, dan munculnya apresiasi hidup karena peran baru diterima dengan kesadaran, ikhlas, dan memiliki perspektif baru paska kehilangan. Hasil ini dapat memberikan acuan agar remaja yang mengalami grief (duka) tidak terperangkap dalam gangguan mental pasca trauma mampu menemukan apresiasi kehidupan sangat ditentukan oleh kualitas asuh, dukungan sosial emosional dan kedewasaan untuk ikhlas dan memiliki perspektif baru bagi hidup barunya.
... Moreover, the multiple selves method enables clients to explore avoided emotions (by giving each emotion a specific chair), build competency and agency when dealing with strong affect (by vacating and returning to specific chairs), and -through use of the compassionate chairestablish a sense of inner coherence and organization . These factors can be helpful in grief, where emotions can be complex, dysregulated, or avoided (Eisma & Stroebe, 2021). By exploring their varied emotional responses to loss, bereaved clients can explore and acknowledge a greater granularity of feeling, which, in turn, allows for a more attuned use of the compassionate self to address associated needs. ...
... These avoidance strategies are seen as maladaptive emotion regulation strategies positively associated with grief reactions (Eisma & Stroebe, 2021). As cross-sectional studies have suggested, depressive avoidance and anxious avoidance are positively correlated with concurrent grief symptoms (Boelen & van den Bout, 2010;Fernández-Alcántara et al., 2021). ...
Bereavement during the COVID‐19 pandemic may have some unique characteristics that become potential risk factors (e.g., absence of grief rituals, no opportunity to say goodbye to the deceased, and loneliness caused by social distancing) for acute grief. Avoidance processes could be significant mediators in the context of the pandemic. The current study aimed to investigate whether and how these COVID‐19‐related risk factors were related to acute grief severity. Bereaved adults (n = 319) who lost significant others during the COVID‐19 pandemic completed a self‐report questionnaire package measuring COVID‐19‐related factors, grief severity, and depressive and anxious avoidance. Regression analyses suggested that among the three potential risk factors (loneliness, grief rituals, and opportunity to say goodbye), loneliness was significantly associated with acute grief after controlling for basic demographic and loss‐related information. Structural equation models suggested that depressive avoidance and anxious avoidance partially mediated the associations of loneliness with acute grief severity. The findings indicate that dealing with loss during the COVID‐19 pandemic warrants further exploration concerning how potential environmental risk factors may impede adaptation to loss. Depressive and anxious avoidance processes may play important roles in grief interventions for isolated and lonely bereaved people.
... In this study, the concept of entrepreneurs' passion restoration is defined as "a process in which an entrepreneur, after experiencing exhaustion, restores passion by adopting certain strategies." Passion restoration is one of the stress management tools of emotional regulatory (Eisma & Stroebe, 2021;Mueller et al., 2017), as well as an integrated strategy for coping with identity loss play in the face of eventual hitting (Conroy & O'Leary-Kelly, 2014;Shepherd & Williams, 2018). ...
The journey of entrepreneurship can be difficult, and passion helps entrepreneurs flexibly adapt to the turbulent environment. However, the entrepreneur’s passion is not constant and can decline or even vanish, especially when faced with entrepreneurial failures. As such, the restoration of an entrepreneur’s passion in the face of failure is a major problem to be solved. Based on in-depth interviews with 21 entrepreneurs, this study applied the grounded theory approach to explore the fundamental factors that lead to a loss of passion as well as its restoration, examine the process of “exhaust-restore-revive” with respect to entrepreneurs’ passion, and construct a matrix of passion restoration based on the concepts of “identity remodeling” and “resource reconstruction.” The findings contribute to an improved understanding of how passion evolves during entrepreneurial activities and the extent to which passion can be restored and revived through different strategies, enriching the research on entrepreneurial passion and the entrepreneurial process. The results have practical implications for using specific strategies to recover passion during the entrepreneurial journey.
... It complicated the responses and grief through thoughts, images, and memories. It focuses on strategies to fight emotion, mindfulness, behavior experience, and practices, (Eisma, & Stroebe, 2021). It also has an effect to the difficulty process of accepting the loss, experiencing the wave of yearning and sadness where the process of mourning takes time but due to the gospel of the Lord Jesus Christ there is an assurance that someday you will meet with your dead ancestors since the teaching of the gospel is family can be together forever. ...
It is all about "Behind the Niche a Memory to Reminisce
... Evidence suggests that emotional regulation strategies, in which individuals influence which emotions they have, when they have them, and how they experience them, 12 are key to coping with grief. 13 Storytelling is one way that individuals may exert control over complex emotions and can be a powerful tool to process distressing experiences. 14 Storytelling has been used in several contexts, including bereavement, to manage emotions and reduce distress. ...
Background: The events surrounding the COVID-19 pandemic have created heightened challenges to coping with loss and grief for family and friends of deceased individuals, as well as clinicians who experience loss of their patients. There is an urgent need for remotely delivered interventions to support those experiencing grief, particularly due to growing numbers of bereaved individuals during the COVID-19 pandemic. Objective: To determine the feasibility and acceptability of the brief, remotely delivered StoryListening storytelling intervention for individuals experiencing grief during the COVID pandemic. Setting/Subjects: A single-arm pilot study was conducted in the United States. Participants included adult English-speaking family members, friends, or clinicians of individuals who died during the COVID-19 pandemic. All participants engaged in a televideo StoryListening session with a trained StoryListening doula. Measurements: Participants completed a brief follow-up telephone interview two weeks after the StoryListening session. We describe enrollment and retention data to assess feasibility and conducted a deductive thematic analysis of the follow-up interview data to assess acceptability. Results: Sixteen clinicians and 48 friends/family members enrolled in the study (n = 64; 75% enrollment), 62 completed a StoryListening session; 60 completed the follow-up interview. Participants reported that the intervention was useful and offered a valuable opportunity to process their grief experience. Conclusions: The StoryListening intervention is feasible and acceptable for friends/family members and clinicians who have experienced grief during COVID. Our intervention may offer an accessible first-line option to address the increasing wave of bereavement-related distress and clinician burnout in the United States.
... Nevertheless, this "perfect" model may be attributable to the confounding effects of rumination, which possibly has mechanistic similarity to loss-focus coping and depression (Eisma et al., 2020). The different dimensions of rumination, including depressive and grief rumination , 2021, were not explored in this study given the scope of the current investigation. However, future studies could augment our findings by examining the effects of specific types of rumination on loss-focus and forward-focus coping and bereavement outcomes. ...
Background and Objectives
Bereavement is a serious public health concern. Some people suffer prolonged and debilitating functional impairment after the death of a loved one. Evidence suggests that flexibility in coping approaches predicts resilience after stressful life events, but its long-term effects after the unique experience of bereavement are unknown. Which strategies of coping flexibility predict better—or worse—adjustment over time for bereaved people and at what times?
Design and Methods
The present study used path analyses to investigate longitudinal effects of forward-focus and loss-focus coping strategies on symptoms of persistent complex bereavement disorder (PCBD), depression, and posttraumatic stress disorder in a spousally bereaved adult sample (N = 248) at three time-points after the loss (∼3 months, ∼14 months, and ∼25 months).
Results
Forward-focus coping demonstrated adaptive utility overall, with sooner effects on PCBD than on depression. By contrast, loss-focus coping demonstrated a delayed-onset, maladaptive pattern.
Conclusions
The findings contribute to the coping flexibility literature by suggesting that the adaptiveness or maladaptiveness of different coping strategies may depend on the context that requires coping. In particular, forward-focus coping may be substantially more advantageous than loss-focus coping in the context of bereavement. Implications, limitations, and future research directions are discussed.
... PGD is characterized by intense longing or yearning for the deceased, a preoccupation with the deceased and/or the circumstances of the death, and emotional pain with symptoms such as difficulties accepting the death, anger or bitterness, a feeling that life is meaningless and wanting to die (suicidal ideation) (Prigerson et al., 2009;Shear et al., 2011). To qualify for the diagnosis of PGD in the ICD-11symptoms must persist for 6 months after the loss and must be associated with functional impairment (Eisma & Stroebe, 2021;Stroebe et al., 2007). A recent study by Rosner et al. (2021) showed a prevalence of 4.2% of a representative sample in the general population when based on the strict criteria of the ICD-11. ...
Despite rising rates of drug-related deaths (DRDs), the consequences of DRDs for bereaved family members are scarcely investigated. This study aimed to estimate the prevalence of prolonged grief (PG) symptoms in bereaved family members after DRDs, identify predictors of PG and examine whether symptom levels decrease with time. A cross-sectional design based on survey data from parents (n = 93), siblings (n = 78), children (n = 24) and other family members (n = 39) was conducted (n = 234). Descriptive analyses, a multivariate linear regression, and ANOVA were performed. 60 family members (26%) suffered from high levels of PG symptoms after DRDs (parents 31.2%, siblings 21.8%, children 20.9%). The strongest associations were found between a high level of symptoms and 'months since the loss', 'suicidal thoughts' and 'withdrawal from others'. The ANOVA analyses showed that time does not always 'heal all wounds', and the bereaved who lost one to 2 years ago had the highest level of PG symptoms.
... The negative impact of rumination may be due to the fact that repetitively going over the cause and consequences of a traumatic event blocks emotional processing, thereby maintaining PTS. Moreover, rumination maintains an inward focus that impairs engagement in constructive action fostering adjustment, thereby perpetuating feelings of traumatic stress as well as depression and grief [51,52]. ...
Non-fatal traffic accidents may give rise to mental health problems, including posttraumatic stress (PTS) and depression. Clinical evidence suggests that victims may also experience grief reactions associated with the sudden changes and losses caused by such accidents. The aim of this study was to examine whether there are unique patterns of symptoms of PTS, depression, and grief among victims of non-fatal traffic accidents. We also investigated associations of emerging symptom patterns with sociodemographic variables and characteristics of the accident, and with transdiagnostic variables, including self-efficacy, difficulties in emotion regulation, and trauma rumination. Participants (N = 328, M age = 32.6, SD age = 17.5 years, 66% female) completed self-report measures tapping the study variables. Using latent class analysis (including symptoms of PTS, depression, and grief), three classes were identified: a no symptoms class (Class 1; 59.1%), a moderate PTS and grief class (Class 2; 23.1%), and a severe symptoms class (Class 3; 17.7%). Summed symptom scores and functional impairment were lowest in Class 1, higher in Class 2, and highest in Class 3. Psychological variables were similarly ordered with the healthiest scores in Class 1, poorer scores in Class 2, and the worst scores in Class 3. Different sociodemographic and accident related variables differentiated between classes, including age, education, and time since the accident. In a regression including all significant univariate predictors, trauma rumination differentiated Class 2 from Class 1, all three psychological variables differentiated Class 3 from Class 1, and difficulties with emotion regulation and trauma rumination differentiated Class 3 from Class 2. This study demonstrates that most people respond resiliently to non-fatal traffic accident. Yet, approximately one in three victims experiences moderate to severe mental health symptoms. Increasing PTS coincided with similarly increasing grief, indicating that grief may be considered in interventions for victims of traffic accidents. Trauma rumination strongly predicted class membership and appears a critical treatment target to alleviate distress.
... 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). ...
In recent years, many studies have been done to identify the factors that affect teacher emotions at schools. However, the empirical evidence on how teachers’ emotions influence students’ outcomes and performance is not extensive. Against this background, this study explored the correlation between teacher EI and student academic achievement and possible mechanisms may lie in this relationship. A sample of 365 Chinese teachers from 25 public middle schools participated in this study by completing measurements of teacher EI, teacher work engagement, and teacher self-efficacy. The student academic achievement was assessed by the grades of the previous term (February to June 2020) reported by the students. The results indicated that teacher work engagement partially mediated the path from teacher EI and student academic achievement. Moderated mediation further showed that teachers with high self-efficacy had a more significant positive impact on the relationship between teacher work engagement and student academic achievement than teachers with low self-efficacy. The limitations of this study were also discussed.
... In the context of loss, one's inability to regulate emotion (i.e., emotion dysregulation) appears to be strongly associated with grief complications, including PGD symptomatology. For example, a recent systematic review identified many emotion regulation studies in the context of loss and found consensus in the literature that maladaptive emotion regulation strategies increased grief difficulties, while adaptive emotion regulation strategies reduced them (Eisma & Stroebe, 2021). In addition, researchers have observed that emotion dysregulation evidenced during interviews about loss are associated with PGD symptoms (Bonanno et al., 2007;Parkes, 1986), including the prospective prediction of grief difficulties a year into the future (Bonanno & Keltner, 1997). ...
A growing body of research demonstrates that religion greatly affects people’s adjustment to loss. However, little is known about the influence of religiosity on emotion regulation during grief. The present study attempts to fill this void in the literature by examining the predictive relationship between variables assessing facets of religiosity and emotion regulation during an interview about loss in a sample of bereaved adults. The results demonstrated that religiousness, spirituality, and negative religious coping were correlated with emotion reactivity following the interview. Spirituality’s influence was also found to be moderated by prolonged grief symptoms, as spirituality predicted more adaptive emotion regulation among those with low to mild levels of prolonged grief symptomatology, but not among participants with elevated prolonged grief disorder (PGD) symptoms. These findings support the beneficial effects of religion in bereavement adjustment as well as its limits.
... However, there were also some limitations to consider. First, both samples were voluntary response samples resulting in an overrepresentation of middle-aged females that typically participate in grief research [47]. This has likely influenced some of the results in this study. ...
Introduction
When grief reactions after bereavement are so intense that they impair daily functioning, a diagnosis of disturbed grief may apply. Slightly differing criteria-sets for disturbed grief are included in the ICD-11, the DSM-5, and its forthcoming text revision, DSM-5-TR. We examined psychometric properties of a new self-report measure, the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+), that assesses these criteria sets for Persistent Complex Bereavement Disorder (PCBD) as per DSM-5, and Prolonged Grief Disorder (PGD) as defined in ICD-11 and DSM-5-TR.
Material and methods
We examined the: i) factor structure, ii) internal consistency, iii) temporal stability, iv) convergent validity, v) known-groups validity, vi) probable caseness, and vii) optimal clinical cut-off scores in two Dutch bereaved samples. Sample 1 consisted of 278 adults, bereaved by various causes. Sample 2 included 270 adults who lost loved ones in a traffic accident.
Results
We found support for a 3-factor PCBD model, 1-factor DSM-5-TR model, and 1-factor ICD-11 PGD model. The DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD items demonstrated good internal consistency and temporal stability. Associations between disturbed grief symptoms and posttraumatic stress and depression levels supported convergent validity. Associations between demographic/loss-related variables and disturbed grief symptoms supported known-groups validity. Optimal clinical cut-offs for the TGI-SR+ total score were ≥75, ≥71, and ≥75 for probable caseness of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD, respectively.
Discussion
While replication of our findings in diverse bereaved samples is needed, we conclude that the TGI-SR+ is a reliable and valid measure to assess symptoms of DSM-5 PCBD, DSM-5-TR PGD, and ICD-11 PGD.
... Experiential avoidance involves any action used by an individual to evade or escape specific thoughts, feelings, memories, physical sensations, and/or other internal experiences (Hayes et al., 1996). Bereaved individuals may suppress internal experiences associated with their loss or avoid places, objects, or situations related to the deceased in attempts to manage distress (Eisma & Stoebe, 2021). Avoidance in grief has been associated with a variety of negative outcomes among bereaved individuals, including an increased amount of intrusive thoughts related to the death (Boelen et al., 2016) and more prolonged grief symptom severity and impairment (Nam, 2016). ...
Background
Distressing preoccupation with the circumstances of the death, experiential avoidance, and yearning often manifest in pathological forms of grief following the sudden or unexpected death of a loved one. Traumatic distress—the emotional distress linked to circumstances or reminders of a death—often leads to avoidance behaviors, whereas yearning has been conceptualized as an emotional state which leads to proximity-seeking behaviors following bereavement. A gap exists in the literature explaining how these variables may interact and perpetuate one another.
Aims
The present study aims to examine the role of experiential avoidance in the relationship between traumatic distress and yearning in a sample of suddenly and unexpectedly bereaved young adults. Results suggest that the association between traumatic distress and yearning may be partially mediated by experiential avoidance. Implications of these findings for theoretical models of grief and yearning are discussed.
Materials & Methods
Data include a sample of 606 bereaved young adults (Mage = 21.25; 77.4% female) who participated in a larger, online survey study conducted at two universities in the United States exploring the prevalence of trauma exposure in college students.
Results
Mediation analysis demonstrated experiential avoidance as partially mediating the relationship between traumatic distress and yearning (ab = .21, SE = .10, 95% CI [.02, .40]) when controlling for presence at the scene of death or injury. This indirect effect accounted for 11.67% of the total effect. An additional moderated mediation analysis indicated this indirect effect was present across all levels of prolonged grief disorder (PGD) symptom severity.
Discussion
Results indicate that the association between traumatic distress and yearning may be partially mediated by experiential avoidance across all levels of PGD symptom severity.
Conclusion
Findings suggest that bereaved individuals experiencing recurrent, death-related intrusive thoughts, imagery, and/or other memories related to the circumstances of the death may be more likely to experience intense yearning for the deceased in part due to attempts to avoid painful internal experiences associated with such cues.
... However, there were also some limitations to consider. First, both samples were voluntary response samples resulting in an overrepresentation of middle-aged females that typically participate in grief research [45]. This has likely influenced some of the results in this study. ...
... Based on these theoretical perspectives, changes in avoidance and maladaptive cognitions are candidate mechanisms of change. Excessive avoidance behavior, such as avoiding to visit the grave or dealing with the belongings of the deceased, avoiding activities associated with the person, or avoiding own thoughts and emotions is frequent in patients with PGD (e.g., Boelen & van den Bout, 2010;Eisma & Stroebe, 2020;Shear et al., 2007). Maladaptive cognitions regarding the form and function of grief, selfblame, or judging one's grief reaction as either too excessive or as the only tie to the deceased, are also common (e.g., Boelen et al., 2006;Skritskaya et al., 2017). ...
Objective: The present study investigated the role of the two theoretically derived mediators in the treatment of Prolonged Grief Disorder (PGD). Mediators were changes in avoidance and maladaptive cognitions. An additional hypothesis tested whether these candidate mediators are specific to CBT-based Complicated Grief Treatment (CGT) compared to Interpersonal Therapy (IPT). Method: We performed secondary analyses with assessment completers (n = 131) from a randomized-controlled trial with older adults with PGD. Patients received 16 sessions of CGT or IPT. Outcomes were treatment response and reductions in grief symptoms and grief-related related impairment. Results: Reductions in avoidance between baseline and week 16 mediated reductions in grief symptoms and grief-related impairment. Reductions in maladaptive grief-related cognitions over the same period mediated treatment response, reductions in grief symptoms and grief-related impairment. There were no significant treatment-mediator interactions. We could not establish that mediators changed before the outcomes. Conclusion: Results are consistent with theoretical models of PGD, including the CGT treatment model. Despite different therapeutic procedures, we found no significant interaction effect, but CGT produced larger effects. Future research needs to establish a timeline of change through the use of multiple measurements of mediators and outcomes.
Trial registration: ClinicalTrials.gov identifier: NCT01244295.
... Whilst studies examining the relationship between emotion regulation and prolonged grief are few in number, they have nevertheless revealed that prolonged grief symptoms are associated with problems with suppressing and enhancing emotional expression (Gupta & Bonanno, 2011), lack of emotional flexibility (Bonanno & Burton, 2013), and limited emotional facial expressions (Diminich & Bonanno, 2014). A recent systematic review has indicated that experiential avoidance and rumination have a critical role in the persistence of prolonged grief (Eisma & Stroebe, 2020). In addition, Gegieckaite and Kazlauskas (2020) showed that emotion regulation difficulties are associated with the severity of prolonged grief. ...
The study aimed to examine the variables that play a role in the process of prolonged grief within the framework of the cognitive-behavioral model. Participants (N = 475) from Turkey took part in a cross-sectional questionnaire survey. The study used structural equation modeling to test a hypothesized model via AMOS v23. After testing two options, the final model was found to be good fit for the data. Results suggested the importance of adopting a comprehensive approach to prolonged grief interventions which includes the loss- and relationship-related factors as well as emotion regulation difficulties, autobiographic memory characteristics, and the grief cognitions.
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.
Prolonged grief disorder, characterized by severe, persistent and disabling grief, has recently been added to the DSM-5-TR and ICD-11. Treatment for prolonged grief symptoms shows limited effectiveness. It has been suggested that prolonged grief symptoms exacerbate insomnia symptoms, whereas insomnia symptoms, in turn, may fuel prolonged grief symptoms. To help clarify if treating sleep disturbances may be a viable treatment option for prolonged grief disorder, we examined the proposed reciprocal relationship between symptoms of prolonged grief and insomnia. On three time points across six-month intervals, 343 bereaved adults (88% female) completed questionnaires to assess prolonged grief, depression, and insomnia symptoms. We applied random intercept cross-lagged panel models (RICLPMs) to assess reciprocal within-person effects between prolonged grief and insomnia symptoms and, as a secondary aim, between depression and insomnia symptoms. Changes in insomnia symptoms predicted changes in prolonged grief symptoms but not vice versa. Additionally, changes in depression and insomnia symptoms showed a reciprocal relationship. Our results suggest that targeting insomnia symptoms after bereavement is a viable option for improving current treatments for prolonged grief disorder.
This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study’s conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention ( p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.
Considerable growth has occurred in research on various aspects of human-animal interaction in recent years. This chapter provides an integrated overview of the current state of empirical research in each of the four core domains of veterinary social work: animal-assisted interventions, animal-related grief and bereavement, compassion fatigue and management, and links between animal and human maltreatment. We discuss strengths and limitations of available knowledge alongside opportunities for future research and, where applicable, data-driven implications for programs and policy.KeywordsAnimal crueltyAnimal-related grief and bereavementAutismCompassion fatigueFamily violenceOlder adultsResilienceTrauma
This study assessed grief reactions amongst individuals who lost a loved one to COVID-19. Differences in attachment-related anxiety, avoidance, and emotion dysregulation were compared between absence, delayed, prolonged, and resolved grief reactions. 146 participants completed self-report measures after they experienced the loss of a parent, sibling, child, or spouse. A series of one-way analyses of variance indicated that there were significant differences in emotion dysregulation and attachment-related anxiety between grief reactions. Additionally, the resolved grief group had the lowest levels of emotion dysregulation. The findings highlight the importance of examining relational and emotional factors in the context of bereavement.
It has generally been understood that the majority of bereaved people suffer from loneliness to at least a moderate degree, and more so than their non-bereaved counterparts. Even before the COVID-19 pandemic impacted social isolation, loneliness had been closely associated with poor mental health outcomes. In this study we systematically review the available, pre-pandemic research on loneliness among the bereaved, noting major patterns of results and certain inconsistencies. On the basis of the general prevalence of loneliness, we suggest an agenda for future research. Research that is theory-based, addresses measurement consistency, systematically investigates correlates and outcomes of loneliness in bereaved as well as non-bereaved groups, and specifies treatment guidelines is necessary to inform future prevention and intervention efforts.
Bereavement may precipitate significant mental health problems. Prolonged grief disorder (PGD) is included in section 2 of the forthcoming DSM-5 text-revision (DSM-5-TR). Research using earlier criteria of disordered grief showed that bereaved people may have distinct symptom patterns—including high, low, and comorbid symptomatology. Building on that work, we used latent class analysis to identity subgroups of bereaved individuals based on their endorsement of symptoms of PGD (per DSM-5-TR), posttraumatic stress, and depression. We also examined if class-membership was associated with socio-demographic and loss-related variables and anxious and depressive avoidance behaviors. Self-reported data were available from 436 people, mostly women, mostly bereaved by the death of their partner or child. Three subgroups were identified, evidencing low symptom levels (34.2%), predominantly PGD symptoms (38.7%), and high symptom levels (27%), respectively. Shorter time since loss, lower education, loss of a partner, and unnatural/violent deaths increased chances of inclusion in the high symptoms class. Anxious and depressive avoidance were lowest in the low symptoms class, higher in the PGD class, and strongest in the high symptoms class. Findings show that PGD per DSM-5-TR is a distinct condition and underscore that reducing avoidance behaviors is important in the treatment of post-loss psychopathology.
Numéro de revue publié sous la direction de Diane Laflamme :
Les articles de ce numéro explorent quelques-unes des trajectoires du mourir qui peuvent rendre le deuil plus dur à porter : quand la mort frappe autour de soi lorsqu’on est encore un enfant ou alors qu’on se sent déraciné de son pays natal, ou encore lorsqu’elle survient à la suite d’un suicide. Le choix que fait une personne de demander l’aide médicale à mourir peut aussi, dans certains cas, susciter des embûches. Certains des textes intègrent à la discussion des considérations sur les médias et les réseaux sociaux en ligne, dont l’usage se répand dans toutes les cultures. En clôture du numéro, deux articles décrivent des façons de rendre plus humaine et plus digne la confrontation à la mort dans le contexte hospitalier. L’un d’eux nous rappelle qu’il est possible, et même bénéfique, de faire une place au rire même lorsque l’échéance connue et annoncée est la mort ; l’autre insiste sur le respect de la dépouille après que la mort ait fait son œuvre.
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.
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.
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.
Three studies evaluated psychometric properties of the Dutch version of the 9-item Acceptance and Action Questionnaire (AAQ)—a
self-report measure designed to assess experiential avoidance as conceptualized in Acceptance and Commitment Therapy (ACT).
Study 1, among bereaved adults, showed that a one-factor model, with AAQ-items constituting a single dimension of experiential
avoidance, fitted the data well. The internal consistency and temporal stability of the AAQ were satisfactory. In Study 2,
among undergraduate students, and Study 3, among 60 outpatients, higher AAQ scores were found to be significantly associated
with psychopathology, maladaptive coping strategies, and neuroticism, attesting to the validity of the measure. In support
of its incremental validity, Study 3 showed that the AAQ remained significantly associated with depression and anxiety after
controlling for neuroticism and thought suppression. The current studies complement prior research supporting the psychometric
properties of the AAQ and the ACT conceptualization of experiential avoidance.
There is burgeoning research on prolonged grief disorder (PGD) among several vulnerable populations but PGD symptoms have been scarcely examined among bereaved internally displaced persons (IDPs). This study investigated the associations of rumination, rebirth concerns and gender with symptoms of PGD following conflict-related bereavement. Participants were 379 Nigerian IDPs who were of the Tiv ethnic group. They provided demographics and completed self-report measures grief and rumination, while concern about rebirth status of the deceased was assessed using a single item which requested participants to indicate whether they had any concerns about the re-incarnation of the deceased. Results showed that gender was not associated with PGD symptoms. High intrusive rumination and high deliberate rumination were associated with increased PGD symptoms in males and females. Rebirth concern was associated with high PGD symptoms in males but not in females. Findings highlight the need for socio-culturally-informed screening/intervention in the wake of conflict-related bereavement.
This article presents results from one of the first longitudinal studies exploring the effects of losing a close friend to traumatic death, focusing on complicated grief over time and how this is affected by avoidant behavior and rumination about the loss. The sample consists of 88 persons (76% women and 24% men, mean age = 21) who lost a close friend in the Utøya killings in Norway on July 22, 2011.Quantitative data were collected at three time-points; 18, 28, and 40 months postloss. Main findings are that bereaved friends are heavily impacted by the loss and their grief reactions are affected negatively by avoidant behavior and rumination. This indicates that close bereaved friends are a group to be aware of and that there is a need for better strategies for identifying individuals in need for follow-up.
The present study investigated differences in various aspects of facial behavior among female patients with complicated grief (CG; n = 18) and healthy controls (n = 18) during the assessment of their attachment representation using the Adult Attachment Projective Picture System. All patients were classified with an unresolved attachment status. On a behavioral level, they demonstrated longer gazing behavior away from the interviewer and the picture stimuli, more speech pauses, less smiling toward the interviewer, and more crying, especially in response to stimuli portraying the theme of loss. Focusing on the in-depth analysis of death-related stimuli using the Facial Action Coding System, patients demonstrated less facial affective behavior, less disgust, and less smiling in response to these stimuli compared with the healthy controls. The impaired capacity of patients with CG responding in an affective appropriate manner regarding bereavement might be interpreted as a specific emotion dysregulation when their attachment and mourning system is activated.
This prospective study examined predictors and correlates of restorative activities in recently bereaved caregivers and their relation to post-bereavement adjustment, namely complicated grief. Participants included 89 caregivers (CGs) age 32-87 (M age - 63 years) whose care recipients recently died in a long-term care facility (M time since loss = 107 days). Our findings show that being prepared prior to death enables CGs the opportunity to engage in restorative activities post death. Restorative activities partially mediated the relationship between preparedness prior to death and complicated grief, but this association was attenuated in multivariable models. It is possible that being prepared prior to death allows CGs to engage in restorative activities post-death, which in turn decreases complicated grief. More research is needed in diverse populations of CGs to determine how restorative activities may impact post-bereavement adjustment.
Background
Grieving individuals demonstrate attentional bias toward reminders of the deceased versus neutral stimuli. We sought to assess bias toward reminders of the deceased versus a living attachment figure and to evaluate similarities and differences in the neural correlates of deceased- and living-related attention. We also sought to identify grief process variables associated with deceased-related attentional bias.
Methods
Twenty-five subjects grieving the death of a first-degree relative or partner within 14 months performed an emotional Stroop task, using words related to a deceased or a living attachment figure, and a standard Stroop task, to identify general selective attention, during functional magnetic resonance imaging. Subjects rated word sadness, complicated grief symptoms, depression severity, attachment style, emotional pain, nonacceptance, yearning, and intrusions.
Results
We identified an attentional bias to deceased-related versus living-related words, independent of age, depression severity/history, loss type, word sadness, medication use, and time since loss. Attentional bias correlated with complicated grief severity and intrusive thinking. A conjunction analysis identified joint activation in the fusiform gyrus, posterior cingulate, and temporal parietal junction across living- and deceased-related attention versus general selective attention. Insecure-avoidant attachment style correlated with decreased engagement of this network in deceased-related attention.
Conclusions
We have demonstrated an attentional bias to reminders of the deceased versus a living attachment in grieving. Overlapping neural circuits related to living- and deceased-related attention suggest that the bereaved employ similar processes in attending to the deceased as they do in attending to the living. Deceased-related attentional bias appears to be linked primarily to intrusive thinking about the loss.
Background:
Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive-behavioral therapy (CBT) has been shown to effectively treat PGD, there is no evidence of long-term effects of CBT.
Objective:
To determine the long-term efficacies of CBT with exposure or CBT without exposure in treating PGD by assessing outcome at 2 years.
Methods:
A randomized controlled trial of PGD patients (N = 80) attending an outpatient clinic took place between September 2007 and June 2010, and a 2-year follow-up occurred between December 2009 and October 2012. All patients received 10 weekly 2-hour group therapy sessions that comprised CBT techniques. Patients also received 4 individual sessions in which they were randomly allocated to receive exposure therapy (CBT/Exposure) for memories of the death or supportive counseling (CBT). Prolonged grief disorder was assessed by clinical interview using the Complicated Grief Assessment. Severity of PGD, the primary outcome, was assessed using the Inventory of Complicated Grief.
Results:
Intent-to-treat analyses indicated a significant linear time × treatment condition interaction effect at 2 years (B = -0.63; SE = 0.26; t₂₂₅ = -2.44; P = .02; 95% CI, -1.14 to -0.12), indicating that CBT/Exposure led to greater reductions in PGD than CBT. Further, the linear between-group effect size at the 2-year follow-up was 1.15.
Conclusions:
Exposure therapy in the course of CBT leads to greater reduction in symptoms of PGD than CBT without exposure, and this additive gain extends 2 years after treatment is complete. To achieve optimal treatment gains in patients with PGD, therapists should encourage some form of exposure therapy to memories of the death.
Trial registration:
Australian New Zealand Clinical Trials Registry identifier: ACTRN12609000229279.
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.
Objective:
In this study, we examined the mechanisms of action of complicated grief treatment (CGT), an efficacious psychotherapy for complicated grief.
Method:
We explored 3 putative mediators (guilt/self-blame related to the deceased, negative thoughts about the future, and avoidance) among treatment completers assigned to either CGT (n = 35) or interpersonal psychotherapy (n = 34) in a previously reported randomized controlled trial. Antidepressant use was examined as a moderator of mediation effects.
Results:
A reduction in guilt/self-blame, negative thoughts about the future, and avoidance behavior each mediated the relationship between treatment group and complicated grief outcomes. Reduction in avoidance emerged as an independent mediator after controlling for all mediators.
Conclusion:
Reducing avoidance of situations and emotions connected to the loss seems to be a key mechanism of change in CGT. Revising counterfactual thinking around troubling aspects of the death may also play a role in facilitating effective adaptation to loss.
Importance
To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the treatment of complicated grief.
Objective
To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT.
Design, Setting, and Participants
Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting.
Interventions
All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions.
Main Outcomes and Measures
Complicated grief–anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of “much improved” or “very much improved.”
Results
Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants’ response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk [RR], 1.51; 95% CI, 1.16-1.95; P = .002; number needed to treat [NNT], 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88-1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean [standard error] difference, −2.06 [1.00]; 95% CI, −4.02 to −0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00-1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82-1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95-1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not.
Conclusions and Relevance
Complicated grief treatment is the treatment of choice for CG, and the