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OMEGA—Journal of Death and Dying
2022, Vol. 0(0) 1–22
© The Author(s) 2022
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DOI: 10.1177/00302228221111946
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Examining the Basic
Assumption of
Psychoanalytic Theory
Regarding Normal and
Abnormal Grief: Roles of
Unfinished Businesses and
Bereavement Related Guilt
Emrah Keser
1
, Yagmur Ar-Karci
2
, and
IlgınG
¨
okler Danıs¸man
3
Abstract
To date, several theoretical models have been proposed to explain how the expected
and natural grief processes turns into psychiatric disorders. Nevertheless, there is a
paucity of empirical research examining the basic assumption of psychoanalytic theory
regarding pre-death conflict and bereavement related guilt. Accordingly, the current
study aimed to investigate the mediator role of bereavement related guilt in the re-
lationship between the pre-death conflict and maladaptive grief process. The sample
consisted of 447 bereaved adults who lost a loved one due to death in the last 5 years.
The Unfinished Business in Bereavement (UBBS), Bereavement Guilt Scale (BGS), Beck
Depression Inventory (BDI), and Prolonged Grief Disorder Scale (PG-13) scales were
administered. The results indicated that the UBBS scores were positively correlated
with both BDI and PG-13 scores, and BGS scores mediated these relationships.
1
Department of Psychology, TED University, Ankara, Turkey
2
Department of Psychology, TED University, Ankara, Turkey
3
Department of Psychology, TED University, Ankara, Turkey
Corresponding Author:
Yagmur Ar-Karci, TED University, Ziya G ¨
okalp Caddesi No: 48, Kolej Çankaya Ankara, Ankara 06420,
Turkey.
Email: yagmur.ar@tedu.edu.tr
Obtained findings were discussed in relation to psychoanalytic theory and existing
studies in the grief literature.
Keywords
psychoanalytic theory, bereavement, grief, prolonged grief disorder, depression
Bereavement, Grief, and Prolonged Grief Disorder
Losing a loved one due to death has long been described as a stressful life event
resulting in a cluster of grief reactions (Prigerson et al., 2009). While the intensity and
chronicity might differ, some similar physical, cognitive, emotional, and psychosocial
symptoms are experienced in grief process (Bonanno & Kaltman, 2001). Most of the
bereaved individuals feel their world has been shattered in the aftermath of the loss and
display acute impairments in their psychosocial functioning. Oscillating between
sorrow and daily tasks, they gradually start to re-invest in interpersonal relations, make
plans, and return to their normal functioning (Stroebe & Schut, 2010). Nevertheless, a
minority of bereaved individuals continue to experience intense grief reactions that tend
not to diminish over time. They are overwhelmed by the sorrow evoked by the loss and
have difficulty in adapting to daily routines notwithstanding the amount of time since
loss. This complex and chronic form of grief has been referred as Prolonged Grief
Disorder (PGD, Prigerson et al., 2009) and characterized by intense yearning, emo-
tional pain, preoccupation with the deceased, identity disruption, disbelief, avoidance,
numbness, loneliness, and difficulty in reintegration into the life after loss (Prigerson
et al., 2021). According to a recent meta-analysis including data from 14 countries, the
prevalence rate of PGD is 9.8% among the bereaved (Lundorff et al., 2017).
Prolonged grief disorder is not the only psychological problem that may arise after a
loss experience. The experience of loss as a major stressor can trigger diverse psy-
chopathologies. It is well-established that one of the most common psychological
problems after the experience of loss is depression (Zisook et al., 2012). Studies
conducted to date have shown that PGD and depression have quite a high comorbidity
ratio (e.g., He et al., 2014;Sung et al., 2011). For example, Simon et al. (2007) found
that approximately 50% of the participants diagnosed with PGD were also diagnosed
with depression. It is also known that there is significant overlap between the symptoms
of loss-related depression and the PGD (Boelen et al., 2016).
Inclusion of PGD in ICD-11 (International Classification of Diseases) and DSM-5-
TR (Diagnostic and Statistical Manual of Mental Disorders) as a separate diagnostic
category (Boelen & Lenferink, 2021;Prigerson et al., 2021) necessitates understanding
of mechanisms underlying prolonged grief symptoms. Accordingly, several attempts
have been made so far to identify psychosocial factors associated with PGD. Amongst
others, (a) closeness or kindship (i.e., child or spouse loss), (b) pre-death relationship
quality, (c) nature of death (i.e., sudden, unexpected or violent), (d) young age of the
2OMEGA—Journal of Death and Dying 0(0)
deceased and bereaved, (e) insecure attachment, dependency and neuroticism traits of
the bereaved, (f) low income, and (g) poor social support were reported as the most
prominent risk factors (Burke & Neimeyer, 2013;Is
¸ıklıet al., 2020;Mason et al., 2020;
Zhou et al., 2020). Although identification of risk factors offers a preliminary ground,
more empirical research is needed to test the utility of theoretical frameworks providing
explanations for the process through which normal grief reactions become pathological.
In his article ‘Mourning and Melancholia’,Freud (1917/1957), for the first time,
highlighted the difference between normal and abnormal grief reactions by delineating
the mechanisms of melancholia. To shed light on grief reactions and abnormal grief, his
work was later expanded by Melanie Klein and Karl Abraham who pointed out the
importance of the pre-death relationship quality and ambivalent feelings (May, 2019).
Nevertheless, there remains a paucity of systematic research testing the psychoanalytic
hypotheses of prolonged grief reactions although evidence is accumulating for other
theoretical models proposed in the literature (e.g., Bio-behavioral Attachment Based
Model, Shear & Shair, 2005; Cognitive Behavioral Model, Boelen et al., 2006; Dual
Process Model, Stroebe & Schut, 2010; and The Two-Track Model of Bereavement,
Rubin, 1999). Accordingly, the present study aimed to investigate the relationship
between unresolved relational conflict, bereavement-related guilt, prolonged grief
symptoms, and depressive symptoms through employing a psychoanalytic perspective.
Psychoanalytic Conceptualization of Grief
Early psychoanalysts including Freud did not aim to conceive grief as a totally ab-
normal condition that needs to be treated. Yet, their conceptualizations lay the
foundations of the modernist views of grief and the mechanisms through which normal
mourning becomes pathological (Granek, 2010). Freud characterized mourning with
intense sorrow experienced upon losing a loved one, diminished interest in the external
world, and incapacity to form attachment with others. He postulated that melancholia
has the very same characteristics but also includes self-reproach, self-pity, ambivalence,
and extreme levels of guilt. In that regard, Freud conceptualized melancholia as a
deviation from non-pathological grief. Individuals with melancholia experience low
self-worth because of persistent self-blaming and have destructive beliefs and feelings
about themselves. Freud explained these tendencies through anger felt toward the lost
object and a shift of the hostility from the deceased to the ego of the bereaved. The lost
object becomes part of the ego through narcissistic identification as id resists to give up
the loved one who once provided love and pleasure. Consequently, anger and re-
sentment towards the lost object is displaced to the ego which manifest itself through
self-accusations and low self-worth. In fact, Freud (1917/1957) believed that such
displacement is more likely in the presence of a conflictual relationship as the libidinal
energy is fixated around the unsolved relational issues with the lost loved one. Melanie
Klein and Karl Abraham further elaborated Freud’s conceptualization and stated that
loving relationships inherently have implicit hostility and hateful qualities. They
claimed that ambivalent feelings towards the deceased might be present not only in
Keser et al. 3
bereaved with melancholia but also in bereaved with non-pathological grief reactions
(Leader, 2009). Accordingly, close relationships contain both affectionate and hateful
qualities simultaneously due to disappointments, unmet expectations, and relational
dependency. Repressing the anger towards the deceased does not exclude the presence
of such hostile feelings (May, 2019;Leader, 2009). Instead, feelings of anger and
hostility towards the deceased are directed to the ego itself and are displayed in the form
of self-blame and low self-value (Freud, 1917/1957). Thus, mourning necessitates
working through the representation of the lost object, representation of the subject and
the feelings originated from the real or imaginary function of the deceased largely
shaped by the nature of pre-death relationship (Bleichmar, 2010).
A much-debated question here is whether Freud’s concept of melancholia coincides
with the symptoms of prolonged grief disorder. Though not identical, there is a great
conceptual overlap between two constructs. In melancholia, there exists a libidinal
fixation with the lost object although what has been lost cannot be articulated. Instead of
freeing libidinal energy from the lost object over time, melancholic individual in-
corporates what has been lost to the ego through narcissistic identification. Conse-
quently, the bereaved is riddled with the feelings of ambivalence, anger and low self-
worth and becomes over attached to the lost object, leaving no room for libidinal energy
to invest in other love objects (Freud, 1917/1957). In fact, this fixation is quite re-
sembling to the lingering anguish, pre-occupation with the lost and difficulty to move
on identified in prolonged grief (Prigerson et al., 2009). Feelings of guilt, self-blame,
low self-worth, emptiness, and loss of pleasure are also evident in depression (Beck,
2011) which is another psychological construct assessed to understand expression of
abnormal grief (Wagner et al., 2021). Additionally, the impoverishment of self in
melancholia due to extreme self-accusations (Freud, 1917/1957) seems to correspond
with the diminished sense of self and meaningless of life in PGD (Prigerson et al.,
2021). Still, a note to caution is due here. We do not claim that melancholia and PGD
are exactly the same psychological responses given during abnormal grieving.
Grounded on psychoanalytic theory, melancholia is an unconscious mental state that
cannot be directly measured through self-report measures of abnormal grief. However,
the conceptual convergence between two phenomena gave us opportunity to empir-
ically investigate the long-proposed association between conflictual relationship with
the deceased, bereavement related guilt and abnormal grief reactions based on the
premises of psychoanalytic theory.
The Current Study
According to psychoanalytic theory, maladaptive grief consists of psychic efforts to
regain the lost object and the relationship with it (Bleichmar, 1996). A persistent
commitment to the lost person functions as a defense against the feelings of guilt that
might be aroused from the real or perceived qualities of the pre-death relationship.
Manifestation of self-blame provides relief from the unbearable grief related emotions
and takes away the responsibility of expressing anger and hostility (Freud, 1917/1957).
4OMEGA—Journal of Death and Dying 0(0)
In other words, explicit expressions of guilt might mask the unconscious hate and rage
towards the deceased building upon a conflictual relationship. Thus, in the current
study, the relationships between (a) unresolved relational conflicts, (b) bereavement
related guilt, and (c) maladaptive grief (prolonged grief and depressive symptoms) were
examined through two proposed models. In the first model, the mediator role of guilt in
the relationship between unresolved relational conflict and prolonged grief symptoms
was tested. In the second model, the mediator role of guilt in the relationship between
unresolved conflict and depressive symptoms was investigated. Based on the proposed
models, it was hypothesized that there is a positive correlation between unresolved
conflict scores and prolonged grief symptoms, and this positive association is mediated
by bereavement related guilt. Similarly, it was expected that the unresolved conflict
scores predict the depressive symptoms scores, and the guilt scores play a mediator role
in this relationship.
Method
Participants
The sample of the current study consisted of adult participants who lost a first-degree
family member. The convenience sampling method was used to reach participants. The
inclusion criteria were (a) being 18 years old or older, (b) having lost a first-degree
family member (parent, spouse, or sibling) at least 6 months and a maximum of 5 years
ago, and (c) volunteering to participate in the study. In total, 447 adults (M
age
= 30.89,
SD = 13.00) participated in the study. Descriptive characteristics of the sample were
represented in Table 1.
Measures
The Unfinished Business in Bereavement Scale. The UBBS is a self-report measurement
tool that consists of unfulfilled wishes and unresolved conflict subscales (Holland et al.,
2020a). While the unfulfilled wishes subscale assesses missed opportunities, unspoken
words, and incomplete experiences, the unresolved conflict subscale assesses conflicts,
anger, and disagreements between the deceased and the bereaved. The UBBS consisted
of 28 Likert type items relating to unfinished business (e.g., “I never got closure on
some important issue or conflict in our relationship’’ ,“I feel a deep sense of anger
toward …that I don’t know how to resolve now that s/he is gone”).The participants
rated the distress level of each unfinished business item on a 5-point scale (1 = Not at all
distressed, 5 = Extremely distressed). Holland et al. (2020b) calculated the Cronbach’s
alpha values for both subscales over .90. The UBBS was translated and adapted into
Turkish by Cesur Soysal (2020). The Cronbach’s alpha values were found to be .93,
.87, and .89 for the entire scale, unresolved conflict subscale, and unfulfilled subscale,
respectively for the Turkish version.
Keser et al. 5
Table 1. Descriptive Characteristics of the Sample.
Variable Mean Standard deviation
Age of bereaved 30.89 13.00
Age of deceased 53.31 24.45
Since loss (Months) 30.61 30.21
Frequency (N) Percentage (%)
Gender
Female 323 72.3
Male 123 27.5
Education level
Primary school 11 2.5
Secondary school 6 1.3
High school 212 47.4
University 144 32.2
Master’s degree 39 8.7
Ph.D. 35 7.8
Marital status
Couple 129 28.8
Single 310 69.3
Other 8 1.8
Income level
Low 31 6.9
Middle 374 83.6
High 42 9.4
Psychiatric history
Yes 62 13.9
No 385 86.1
Current psychiatric treatment
Yes 43 9.6
No 404 90.4
Closeness
Mother 35 7.8
Father 72 16.1
Sibling 15 3.4
Spouse 2 0.4
Child 3 0.6
Grandmother 76 21.7
Grandfather 97 21.7
Aunt 28 6.3
Uncle 31 6.9
Close friend 32 7.2
(continued)
6OMEGA—Journal of Death and Dying 0(0)
The Bereavement Guilt Scale. Bereavement guilt scale is a self-report instrument as-
sessing bereavement related guilt (Li et al., 2017). It includes 14 items measured on a 5-
point Likert type format. BGS has five sub-scales that are (1) responsibility for death,
(2) hurting the deceased, (3) survivor guilt, (4) indebtedness guilt and (5) guilt feeling.
In the original study, the Cronbach’s alpha values ranged between .74 and .92, and the
test-retest reliability of the total scale was .92. BGS was adapted to Turkish by Keser
et al. (2021). The Turkish version showed a good fit with the original form consisting of
5 factors and 14 items. The Cronbach’s alpha values ranged between .70 and .88 for the
subscales while the internal consistency was .88 for the total scale. In the current study,
the Cronbach’s alpha value was found as .88 for the entire scale.
The Prolonged Grief Disorder Scale (PG-13). Prolonged grief disorder scale is a self-report
instrument assessing intensity of prolonged grief symptoms (Prigerson et al., 2009).
The 13-item scale measures separation distress, sorrow, yearning, emptiness, emotional
pain, role confusions and difficulty to move on. Higher scores indicate more intense
prolonged grief symptoms. The internal consistency of the original scale was .90. The
Turkish adaptation of PG-13 was performed by Is
¸ıklıet al. (2020), and the Cronbach’s
alpha value was reported as .90. Cronbach’s alpha value regarding the PG-13 items was
.91 in the current study.
Table 1. (continued)
Variable Mean Standard deviation
Cousin 29 6.5
Girlfriend/Boyfriend 5 1.1
Other 22 4.9
Cause of death
Heart attack 84 18.8
Cerebral hemorrhage 23 5.1
Cancer 127 28.4
Chronic obstructive pulmonary disease 9 2
Alzheimer/Dementia 17 3.8
Organ failure, diabetes, high blood pressure 45 10.1
Traffic accident 23 5.1
Work accident 4 0.9
Suicide 14 3.1
Homicide 4 0.9
Terror attack 6 1.3
Elderliness 67 15
Other 24 5.4
Keser et al. 7
Beck Depression Inventory. Beck depression inventory is 21-item self-report instrument
measuring emotional, cognitive, and behavioral/physiological symptoms of depression
(Beck et al., 1961). Items are rated on a 4-point Likert type format. Greater scores
indicate more severe depression. The Turkish adaptation was performed by Hisli
(1989), and the internal consistency value was reported as .93. The Cronbach’s alpha
value of BDI was .89 in the current study.
Procedure
Ethical approval was obtained from X University Human Research Ethics Committee.
The data were collected between 2019 and 2020 in Turkey through convenience
sampling procedure. Online versions of the measurement tools were created, and the
data was obtained using www.survey.com, a free website. An announcement was made
including the purpose of the study and the inclusion criteria via social media and e-mail
groups. In addition, X University Psychology Department students were asked to share
the announcement with their social networks. People who volunteered to participate to
the research filled out the online survey battery by clicking on the link in the an-
nouncement text. Duration for the completion of survey battery was examined and three
participants were excluded from the data due to extremely short response time (between
1 and 5 min).
Data Analysis
Statistical Package for Social Sciences (SPSS) 24 and Hayes PROCESS MOCRO 4.0
for SPSS (Hayes, 2013) were used in the analyses. Before running the analyses, the data
were evaluated in terms of missing values and outliers. Missing value rates were under
1% for all items, and they were inputted with mean. Outliers were investigated by
calculating z-scores of the total scores of three scales in the study. It was seen that all
z-scores were in the range of 4 and +4. Mertler et al. (2021) stated that if the sample
size is larger than 100, 4 and +4 limits could be used to detect outliers. Therefore, no
participant response was deleted because of extreme scores.
The normality assumption was tested by using z-scores of skewness and kurtosis
values of the PG-13, BGS, UBBS, and BDI scores. The skewness and kurtosis values
were divided by their errors and the z scores were found as 0.9 and 3.95 for the UBBS
scores, 6.72 and 0.04 for the BGS scores, 7.18 and 0.17 for the PG-13 scores, 6.72 and
1.30 for the BDI scores. Field (2018) stated that if z-scores of skewness and kurtosis
values are in the range of 1.96, and +1.96, the normality assumption is met. As a
result, it was inferred that the normality assumption was not met for the variables in the
study. Second, the linearity assumption was tested using scatter plot graphs. It was
observed that there was not any curvilinear relationship between the variables. The
multicollinearity assumption was evaluated using Pearson correlation coefficients
between the variables. The correlation values were between .35 and .64. Because these
8OMEGA—Journal of Death and Dying 0(0)
values were not greater than .70, it can be inferred the multicollinearity assumption was
met.
To reduce bias caused by violation of the normality assumption, a bootstrapping
method (Preacher & Hayes, 2008) was used with 5000 resampling and bias accelerated
confidence intervals in the mediation analyzes. The bootstrapping method is used to
reduce the bias that occurs when data do not meet the assumptions for parametric
analyses. The bootstrap procedure creates thousands of different samples from the
existing sample and repeatedly conducts the analysis on these generating samples. It
reports the range of 95% of the findings obtained in analyzes repeated thousands of
times. Thanks to this feature of Bootstrap, it is possible to obtain more reliable results
from data that is not normally distributed (Field, 2018, p. 366–369).
Two separate multiple regression analyses were conducted to investigate demo-
graphic risk factors of prolonged grief and depressive symptoms. Two mediation
analyzes were conducted using Model four in the PROCESS Macro for SPSS (Hayes,
2013) to investigate the mediator role of guilt score in the relationships between
unfinished business, prolonged grief symptoms, and depressive symptoms after
controlling for demographic risk factors. In the first analysis, the UBBS, BGS, and PG-
13 scores were assigned as predictor, mediator, and outcome, respectively. In the
second analysis, the UBBS, BGS, and BDI scores were included in the regression
equation as predictor, mediator, and outcome, respectively.
In model 1, a, b and c’represented direct effects. Besides, to see the indirect effect, a × b
was calculated.
In Model 2, a
2,
b
2,
and c
2
’paths represented direct effects and the interaction effect was
evaluated by calculating a
2
×b
2.
Keser et al. 9
Results
Descriptive Statistics
Descriptive statistics were presented in Table 2. Pearson correlation coefficients be-
tween the variables were presented in Table 3. As seen in Table 3, Person correlation
coefficients were found between .35 and .64. All correlation coefficients were sig-
nificant at p< .001 level.
The correlation coefficients between subscales of the BGS and UBBS were showed
in Tables 4 and 5.
Results of Multiple Regression Analyses
Two separate multiple linear regression analyses were conducted to investigate the
relationship between demographic variables such as age, gender, marital status, in-
come, education, elapsed time since loss, and age of the deceased. As seen in Table 6,
the age of the deceased was found to be a significant predictor of both prolonged grief
and depressive symptoms. As the age of the deceased decreased, the PG-13 and BDI
scores increased. Besides, the unexpected nature of the loss was found to be a risk factor
for the PG-13 scores. Variables that were found to be significant in the regression
analyses were assigned as the control variables in the mediation analyses.
Table 2. Descriptive Statistics Related to the Variables of the Study.
Mean Standard deviation Minimum Maximum
PG-13 24.84 9.07 11.00 55.00
BDI 11.92 8.49 0.00 46.00
UBBS total 64.80 22.12 28.00 139.00
Subscales
Unfulfilled wishes 12.97 4.91 4.00 20.00
Unresolved conflict 5.94 2.58 4.00 20.00
BGS total 26.54 9.74 14.00 70.00
Subscales
Responsibility for death 3.92 2.06 3.00 15.00
Hurting the deceased 4.66 2.24 3.00 15.00
Survivor guilt 4.58 2.40 3.00 15.00
Indebtedness guilt 7.94 3.40 3.00 15.00
Guilt feeling 5.42 2.81 2.00 10.00
PG-13 = The Prolonged Grief Disorder Symptoms Scale total score; BDI = Beck Depression Inventory total
score; UBBS = The Unfinished Business in Bereavement Scale total score; BGS = Bereavement Guilt Scale
total score.
10 OMEGA—Journal of Death and Dying 0(0)
Results of the Mediation Models
A mediation analysis was conducted using Hayes PROCESS macro with bootstrapping
method to determine whether the BGS scores mediated the relationship between the
UBBS scores and the PG-13 scores. After controlling for the age of the deceased and
unexpected nature of loss variables, the total effect of the UBBS scores on the PG-13
scores was significant (b = .21, SE = .02, t = 12.51, BCa 95% [.18, .24]). All the direct
effects in the model (paths a, b, and c’) were found to be significant (Table 7). To test the
mediator role of the BGS scores, indirect effect (a x b) was calculated and found to be
significant (b = .08, SE = .01 BCa %95 [.05, .11].
Another mediation analysis was performed to test Model two using Hayes PROCESS
macro with bootstrapping method. The results revealed that the total effect of the UBBS
Table 3. The Pearson Correlation Coefficients Indicating the Relationships Between the
Variables.
12 3 4
1-PG-13 .52* .56* .54*
2-BDI .35* .47*
3-UBBS .64*
4-BGS
*p< .001, PG-13 = The Prolonged Grief Disorder Symptoms Scale; BDI = Beck Depression Inventory;
UBBS = The Unfinished Business in Bereavement Scale; BGS = Bereavement Guilt Scale.
Table 4. The Pearson Correlation Coefficients Between the BGS Total and its Subscales.
123456
1-BGS total .64* .76* .72* .78* .83*
2-Responsibility for death .44* .56* .25* .37*
3-Hurting the deceased .39* .53* .54*
4-Survivor guilt .32* .52*
5-Indebtedness guilt .61*
6-Guilt feeling
*p<.001, BGS = Bereavement Guilt Scale.
Keser et al. 11
scores on the BDI scores was significant (b= .14, t = 7.67, BCa 95% [.10, .17]) after
controlling for the age of the deceased variable. When UBBS scores and BGS scores
were included in the regression equation together, the predictive role of UBBS on BDI
scores became non-significant (b=.04,p=.09,BCa95%[–.01, .08]. Indirect effect (a
2
×
b
2
) was found to be significant (b=.10,SE = .02 BCa %95 [.07, .14]. The Model 2
schema is incomplete. The indirect effect and total effect values, ant the arrow repre-
senting the regression weight are missing.
Table 5. The Pearson Correlation Coefficients Between the UBBS Total and its Subscales.
12 3
1-UBBS Total .92* .68*
2-Unfulfilled wishes .35*
3-Unresolved conflict
*p< .001, UBBS = Unfinished Business in Bereavement Scale.
Table 6. Multiple Regression Results.
Outcome: PG-13 scores Outcome: BDI scores
βSE 95% CI βSE 95% CI
Predictors
Age .09 .05 .08, .19 .01 .05 .09, .10
Gender 1.56 .96 3.44, .31 1.12 .94 2.97, .73
Marital status 2.54 1.36 .14, 5.23 2.44 1.34 .21, 5.10
Education .41 .42 .41, 1.22 .31 .41 1.11, .50
Income level 1.51 1.03 .52, 3.53 .53 1.01 2.52, 1.46
Nature of the death (expected/
unexpected)
1.73* .33 -2.37, 1.08 .28 .32 .92, .35
Elapsed time since loss .02 .01 .05, .01 .01 .01 .33, .02
Age of deceased .08* .02 .12, .05 .04* .02 .70, .000
*p<.05, B = Unstandardized beta; SE = Standard error; 95% CI = Confidence intervals.
12 OMEGA—Journal of Death and Dying 0(0)
Discussion
The current study aimed to test the basic assumption of the psychoanalytic theory
regarding bereavement and grief through the lenses of the quantitative methodology.
Two mediation models were proposed and tested for this aim. Before testing the
mediation models, the relationship between demographic characteristics, prolonged
grief symptoms, and depressive symptoms were investigated. It was seen that the young
age of the deceased was a risk factor for both prolonged grief and depressive symptoms.
Besides, unexpected death was a risk factor for prolonged grief symptoms.
In the first mediation model proposed within the scope of the study, the relationship
between unfinished business and the symptoms of prolonged grief; and the mediating
role of bereavement related guilt in this relationship were examined. The age of the
deceased and nature of the death (i.e., expected/unexpected) were controlled. In the
second mediation model, the relationship between unfinished business and depressive
symptoms, and the mediating role of bereavement related guilt in this relationship were
tested. The age of the deceased was controlled. Both models were found to be con-
firmed by the obtained data. As suggested in the first model, as the level of unresolved
relational conflict, unspoken words, missed opportunities in the pre-death relationship
increased, prolonged grief symptoms also increased. Further, bereavement related guilt
was found to play a mediating role in this relationship. Similarly, in the second model, a
positive relationship was found between the level of unresolved conflict, unspoken
words, missed opportunities in pre-death relationship and depressive symptoms. It was
also found that bereavement related guilt mediated this relationship. These findings are
Table 7. Standardized Betas, Standard Errors, and Confidence Interval Values of the Mediation
Models.
bSE BCa CI 95%
Lower Upper
Model 1
Total effect .21* .02 .18 .24
Path a .28* .02 .25 .32
Path b .28* .05 .19 .37
Path c’.13* .02 .09 .17
Indirect effect (a × b) .08* .01 .05 .11
Model 2
Total effect .14* .02 .10 .17
Path a
2
.28* .02 .25 .32
Path b
2
.36* .05 .27 .45
Path c
2
’.04 .02 -.01 .08
Indirect effect (a × b) .10* .02 .07 .14
*p< .001; b = Standardized beta values;
SE = Standar error; BCa CI = Confidence Intervals based on 5000 bootstrap samples.
Keser et al. 13
consistent with the previous research findings in the literature. It is possible to come
across several studies showing that a conflicted relationship before death predicts
symptoms of prolonged grief and depression. For instance, Smigelsky et al. (2019)
found that increased conflict in the pre-death relationship was associated with an
increase in grief symptomatology. In another study conducted with a sample of mothers
who lost their children, Feigelman et al. (2009) reported that mothers who evaluated
their pre-death relationship with their child as ‘negative/uncertain’experienced sig-
nificantly higher levels of grief symptoms than mothers who evaluated their rela-
tionship as ‘positive’. Similarly, in a study conducted by Mash et al. (2014) with young
adults who lost a family member or a close friend, pre-death dependent relationship
with the deceased was found to be associated with both prolonged grief and an increase
in depressive symptoms. Also, feeling indebted to the deceased, as well as dependency
in the relationship was identified as a risk factor for prolonged grief symptoms.
Klingspon et al. (2015) showed that unfinished business, unspoken words, and un-
resolved conflicts in the pre-death relationship were associated with prolonged grief
symptoms and global psychiatric distress. In parallel, in Lichtenthal et al.’s (2020)
mixed design study conducted with parents who lost their child due to cancer, 33% of
the parents reported unfinished businesses which were found to be associated with
regret and distress.
Although most of the previous studies revealed that the conflict in the pre-death
relationship is positively related to maladaptive grief outcomes, there are also studies
that reporting the opposite. For instance, in their longitudinal study conducted with
adults with spousal loss, Bonanno et al. (1998) exerted that the ambivalent emotions
were associated with distress, poor perceived health, and grief symptoms. On the other
hand, they found that the ambivalent feelings experienced after the loss did not predict
later grief outcome. Similarly, Piper et al. (2001) found a negative relationship between
ambivalent feelings and the severity of grief symptoms.
When the findings of the research examining the role of guilt in the grieving process
are examined, it is seen that guilt shows strong relationships with both prolonged grief
and depressive symptoms. For example, Wagner et al. (2021), in their study conducted
with adults who lost their relatives due to suicide, showed that guilt predicted prolonged
grief, depression, and posttraumatic stress symptoms after controlling for socio-
demographic variables. Similarly, in a longitudinal study conducted by Li et al.
(2019), it was found that feelings of guilt experienced after loss predicted pro-
longed grief and depression symptoms 1 year later. Camacho et al. (2018) examined the
relationship between diverse loss experiences and guilt and reported that the parents
with child loss due to suicide were representing the group that experienced the highest
levels of guilt. They stated that as the severity of guilt increases, emotion regulation
becomes harder.
As can be seen, the relationship between pre-death relationship conflict, guilt, and
the maladaptive grief process has been widely examined by researchers. The current
study expands the scope of the previous studies in the literature investigating these
variables with two mediator models proposed within the framework of psychoanalytic
14 OMEGA—Journal of Death and Dying 0(0)
theory. Another important contribution of the present study is that it tests the basic
premise of psychoanalytic theory with empirical data. Among the grief models sug-
gested so far (e.g., Bio-behavioral Attachment Based Model, Cognitive Behavioral
Model, Dual Process Model, and The Two-Track Model of Bereavement) the grief
model of psychodynamic theory has been the least tested one using quantitative data. It
is thought that the current study would contribute to the literature by helping to fulfill
this gap.
Freud stated that in abnormal grief (i.e., melancholia), ambivalent feelings, guilt and
self-deprecating symptoms are observed, and melancholy differs from grief in terms of
these symptoms (Freud, 1917/1957). According to Freud, individuals who are in a state of
melancholy feel intensive guilt, their self-esteem is destroyed, and they have highly de-
structive and devaluing feelings and thoughts towards themselves. The underlying reason
of this guilt and self-hatred is the anger and ambivalent feelings towards the deceased. At
this point, the following question comes to mind: Why do people feel angry towards
individuals they are deeply sorry for losing? After Freud’s article Mourning and Mel-
ancholia, Karl Abraham, and Melanie Klein, who addressed the subject again, opposed
Freud’s categorical approach which implies that ambivalent feelings are present only in
some relationships. Instead, they stated that love and anger coexist in all intimate rela-
tionships, and they are not specific only to some relationships (Leader, 2009). The psy-
chodynamic approach explains the transformation of normal mourning into abnormal
mourning through ego-directed anger and guilt (Freud, 1917/1957). When loss is expe-
rienced, anger and hatred towards the close person are internalized with narcissistic
identifications and become a part of the ego. Thus, anger is directed at the mourner’sself,
leading to intense feelings of worthlessness and guilt. Aggression towards the ego is
manifested by feelings of guilt and a decline in self-worth. In cases where the pre-death
relationship was experienced as a conflictual one, the anger towards the deceased remains
objectless with the loss. Anger that fails to find an object is directed towards the ego, that is,
the person herself/himself (Milrod, 1988). Confirmation of the two mediator models tested
in the current study has provided support for the assumption that anger and hatred arousing
from the conflictual relationship with the deceased may be directed towards oneself after
death, being manifested as feelings of guilt and self-blame.
In the current study, one of the main hypotheses of the psychodynamic theory on
grief has been tested; however, it is not possible to claim that the findings can solely be
explained by psychoanalytic theory. The present findings can also be interpreted using
the cognitive behavioral model of grief (Boelen, 2006:Boelen et al., 2006). According
to the cognitive model, negative cognitions during the grieving process can cause
people to experience the usual grieving process more intensely and for a longer duration
(Boelen, 2006). When individuals who have experienced a loss develop negative
cognitions regarding their grief symptoms, their role in the occurrence of the loss, and/
or their past relationships with the deceased, an increase is observed in the level of
feelings such as guilt, sadness, and anxiety (Boelen & Lensvelt-Mulders, 2005).
Another point to consider when evaluating research findings is the fact that since
many of the concepts derived from psychoanalytic theory are related to structures
Keser et al. 15
functioning at the unconscious level, they cannot be accurately assessed by the
measurement tools used by the contemporary science of psychology. It is often not
possible to make operational definitions of unconscious structures. This deprives the
highly useful hypotheses of psychoanalytic theory from being tested. Psychoanalytic
theory’s deep and meaningful explanations suggested at the universal level have been
perceived as hearsay and vague descriptions for many years because they have not been
tested with research findings (Lemma, 2003,p.6–7). On the other hand, psychoanalytic
theory is not a theory that focuses only on psychotherapy and ignores the field of
research. In the last two decades, research aiming to deal with the concepts and hy-
potheses of psychoanalytic theory based on empirical evidence, especially in the field
of neuropsychoanalysis, has increased. A similar approach was adopted in the present
study. Freud considered the concept of Melancholia as the result of an unconscious
identification process and ambivalence. It does not seem possible to make an oper-
ational definition of this construct in accordance with today’s methodological un-
derstanding. On the other hand, as researchers, we do not think that this structure could
never be addressed in empirical studies. About 100 years ago, Freud made the dis-
tinction between normal and abnormal mourning using the categories of mourning and
melancholia. Today, in diagnostic classification systems such as DSM-5-TR and ICD-
11, the prolonged grief disorder is the corresponding term for abnormal grief. Although
we cannot directly measure the concept of melancholia as defined by Freud, we believe
that instead by measuring the symptoms of prolonged grief and depression using PG-13
and BDI scales, we can evaluate the symptoms of grief that have deviated from its
normal course and became pathological.
Limitations
In the grief model proposed by the psychodynamic theory, ambivalent emotions are
considered as the determinants of prolonged grief. It would be very difficult to evaluate
psychoanalytic constructs with self-report type measurement tools because of their
implicit and unconscious nature. The use of retrospective self-report measures was
another limitation of the current study. There may have been resistance among the
participants in reporting conflicts in the pre-death relationship, given the possibility that
the deceased may be idealized. In addition, memory bias and current emotional state
might affect their response. It can be thought that the generalizability of findings of the
current study is limited due to the nature of convenience sampling method. Besides, the
use of cross-sectional research design does not allow establishing a cause-effect re-
lationship between the variables.
Clinical Implications
Various treatment protocols are used in the treatment of prolonged grief. Among these,
the most well-known ones are Complicated Grief Treatment (Shear et al., 2005),
Cognitive Behavioral Therapy for Complicated Grief (Boelen et al., 2007), Meaning
16 OMEGA—Journal of Death and Dying 0(0)
Reconstruction Therapy (Neimeyer, 2016), Narrative Approach (Alves et al., 2014;
Neimeyer, 1999), Group Psychotherapies (e.g., Kealy et al., 2019;Piper et al., 2007),
and online interventions (Wagner et al., 2020). In most of these intervention schools,
there is no specific agenda for the study of conflicts, ambivalent feelings, and guilt in
the pre-death relationship.
On the other hand, psychotherapists working with grieving individuals need to be
prepared for feelings of guilt and the consequences of a conflictual relationship with the
deceased, regardless of their therapy school or protocol. Alves et al. (2016) stated that
ambivalent emotions can block the progress of grief therapy, and that handling these
emotions in therapy is associated with change. In another study, Alves et al. (2014)
stated that the ambivalent feelings that emerged in the bereavement therapy were
related to the thoughts that the client betrayed the deceased by participating in the
therapy process. Therefore, focusing on unfinished business and plans, unspoken
words, unexpressed emotions, and the themes of guilt and regret that may be associated
with them during the grieving process can be integrated into therapy protocols, not only
as a form of psychodynamic work, but also as transtheoretical components.
Conclusions
In this research, the main aim was to investigate the relationship between unfinished
business, bereavement related guilt and maladaptive grief (i.e., prolonged grief and
depression). We established our hypotheses based mainly on Freud’s work on mel-
ancholia and psychoanalytic conceptualizations of normal and pathological grief. The
most obvious finding to emerge from this study is that bereavement related guilt
mediated the relationship between conflictual pre-death relationship and maladaptive
grief reactions including PGD and depression. This finding provide support for the
psychoanalytic assumption suggesting that anger and hostility pertaining to the real or
perceived relationship with the deceased might be expressed as feelings of guilt in the
context of a conflictual pre-death relationship while experiencing maladaptive grief
symptoms.
Author Contributions
All authors made substantial contributions to the conception and design of the work. Material
preparation, data collection, and analysis were mainly performed by Emrah Keser. Interpretation
of the results was performed by Emrah Keser and Yagmur Ar-Karci. Writing, reviewing, and
editing of the manuscript were conducted by the research team together. All authors read and
approved the final version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Keser et al. 17
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this
article.
ORCID iDs
Emrah Keser https://orcid.org/0000-0003-0830-2970
Yagmur Ar-Karci https://orcid.org/0000-0003-4197-3848
Ethics Approval
Approval was obtained from the TEDU Human Subjects Ethics Committee (HREC). The
procedures used in this study adhere to the tenets of the Declaration of Helsinki. Written informed
consent was obtained for participation and dissemination of the results. Identity of the partic-
ipants were carefully distorted during data analysis and reporting of the results.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the
corresponding author on reasonable request.
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