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Journal of Social Work in End-of-Life & Palliative Care
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wswe20
The Effects of Bereavement Time on the
Relationship Between Coping Strategies and
Psychological Distress
Tomohiro Uchida, Noriaki Satake, Chiin Takayama, Akari Uno, Toshimichi
Nakaho, Akira Inoue & Hidemitsu Saito
To cite this article: Tomohiro Uchida, Noriaki Satake, Chiin Takayama, Akari Uno, Toshimichi
Nakaho, Akira Inoue & Hidemitsu Saito (2022) The Effects of Bereavement Time on the
Relationship Between Coping Strategies and Psychological Distress, Journal of Social Work in
End-of-Life & Palliative Care, 18:3, 235-251, DOI: 10.1080/15524256.2022.2093315
To link to this article: https://doi.org/10.1080/15524256.2022.2093315
Published online: 01 Jul 2022.
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The Effects of Bereavement Time on the Relationship
Between Coping Strategies and Psychological Distress
Tomohiro Uchida
a
, Noriaki Satake
b
, Chiin Takayama
a
, Akari Uno
c
,
Toshimichi Nakaho
d
, Akira Inoue
b
, and Hidemitsu Saito
e,f
a
Division of Psychology, Shokei Gakuin University, Natori, Japan;
b
Palliative Care Center, Tohoku
University Hospital, Sendai, Japan;
c
Graduate School of Education, Tohoku University, Sendai,
Japan;
d
Department of Palliative Care Medicine, Miyagi Cancer Center, Natori, Japan;
e
Psychiatric
Nursing, Tohoku University School of Medicine, Sendai, Japan;
f
Department of Psychiatry,
Midorigaoka Hospital, Shiogama, Japan
ABSTRACT
The purpose of this study was to investigate the relationship
between bereaved individuals’coping patterns, mental health,
and time post-loss. A questionnaire using the Coping with
Bereavement Scale (CBS) and the Kessler Psychological
Distress Scale (K6) was completed by 173 family members of
individuals who died from cancer between August 2013 and
March 2016. Confirmatory factor analysis revealed a three-
factor solution for the CBS comprised of “life orientation,”
“avoidance,”and “retaining ties”with the deceased. Scores on
retaining ties were significantly but weakly correlated with K6
scores; however, the intensity of this relationship increased
with more time post-bereavement, and individuals who
retained strong ties with the deceased for two years or more
demonstrated poorer mental health. Although retaining ties
with the deceased might be an adaptive psychological pro-
cess following bereavement, in this study, long-term persist-
ence with that coping strategy was associated with greater
overall psychological distress. Further research is needed to
identify optimal coping methods to address evolving needs
during the bereavement process.
KEYWORDS
Coping; family caregivers;
period after bereavement;
psychological distress;
retaining ties
Losing a spouse or close relative is one of the most stressful events that can
occur in a person’s life (Haley, LaMonde, Hab, Narramore, & Schonwetter,
2001). Previous studies have found that most bereaved individuals eventu-
ally overcome their grief without intervention ( Aranda & Milne, 2000;
Stroebe, Schut, & Stroebe, 2007); however, 5–33% of individuals experience
prolonged and severe post-loss psychological distress, which is widely
referred to as complicated grief or prolonged grief disorder (Schut &
Stroebe, 2005; Tsai, Kuo, Wen, Prigerson, & Tang, 2018). Individuals expe-
riencing complicated grief are at heightened risk for poor mental health,
CONTACT Tomohiro Uchida to_uchida@shokei.ac.jp Division of Psychology, Shokei Gakuin University, 4-
10-1, Yurigaoka, Natori, Miyagi 981-1295, Japan
ß2022 Taylor & Francis Group, LLC
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
2022, VOL. 18, NO. 3, 235–251
https://doi.org/10.1080/15524256.2022.2093315
including anxiety, depression, insomnia, and suicide (Ajdacic-Gross et al.,
2008; Boelen, 2013; Ghesquiere, Haidar, & Shear, 2011). In contrast to the
typical spontaneous resolution of grief, these prolonged outcomes often
require intervention.
Reducing the likelihood of prolonged bereavement-related outcomes
requires the ability to identify and predict potential risk factors. A number
of studies have highlighted coping methods as a strong predictor of post-
loss outcomes (Eisma et al., 2014a; Eisma, Boelen, Schut, & Stroebe, 2017;
Kissane, McKenzie, & Bloch, 1997). The variety of strategies that individu-
als employ to cope with loss can be broadly classified as either proactive or
avoidant. Proactive coping styles include problem-solving, actively engaging
in emotional and cognitive dialogue, and reframing as means of processing
grief (Carver & Scheier, 1994; Folkman & Lazarus, 1985). Such active proc-
esses often manifest as help-seeking behaviors (i.e., counseling, therapy,
religion, and spiritualization) and are generally associated with positive
mental health and quality of life outcomes (Cousins, Servaty-Seib, &
Lockman, 2017; Drapeau, Cerel, & Moore, 2016; Schnider et al., 2007).
However, other coping habits are perceived as maladaptive, such as rumin-
ation, social withdrawal, avoidance, denial, distraction, and retaining ties
with the deceased, among others. These avoidant coping styles are widely
associated with increased levels of depression, anxiety, guilt, and poorer
overall quality of life ( Boelen & Reijntjes, 2016; Pham et al., 2018; Tsai
et al., 2018).
Rumination has been variously conceptualized as a strategy that increases
the availability of negative cognitions (e.g., Nolen-Hoeksema, 2001) and an
avoidance strategy that serves as an escape from admitting the facts of the
loss and confronting the most painful aspects of the bereavement experi-
ence (Boelen, Stroebe, Schut, & Zijerveld, 2006; Eisma et al., 2014a,2015).
Previous studies have linked rumination (i.e., repetitive thoughts about a
sustained loss), retaining ties with the deceased, and regularly recounting
fond memories with poor mental health outcomes, including depression
(Boelen, Stroebe, et al., 2006; Eisma et al., 2014a,2015; Field, Gal-Oz, &
Bonanno, 2003; Scholtes & Browne, 2015). Nolen-Hoeksema and
colleagues describe rumination as a depressive behavior whereby the
bereaved individual repetitively and recurrently focuses on grief-related
emotions in a passive manner rather than taking action to relieve their dis-
tress (Nolen-Hoeksema, 2001; Nolen-Hoeksema, McBride, & Larson, 1997;
Nolen-Hoeksema, Parker, & Larson, 1994). Studies have demonstrated the
negative impact of depressive rumination on grief recovery, including
higher levels of depression, anxiety, posttraumatic stress, and complicated
grief (Eisma et al., 2014b,2015; Morina, 2011; Nolen-Hoeksema et al.,
1997), particularly in cases when this strategy persists for several months
236 T. UCHIDA ET AL.
after the loss (Nolen-Hoeksema et al., 1994). However, some researchers
have also differentiated between adaptive or deliberate and maladaptive or
intrusive rumination, whereby the former entails more self-focused think-
ing and active coping behavior directed toward understanding and resolv-
ing emotional reactions (Eisma et al., 2014a).
Similarly, retaining ties with the deceased, also known as continuing
bonds (Klass, Silverman, & Nickman, 1996), is not necessarily maladap-
tive, and continued connections are not always an indicator of poor
mental health (Bonanno, Wortman, & Nesse, 2004; Carnelley, Bolger,
Wortman, & Burke, 2006; Shaver & Tancredy, 2001). A growing body
of literature has proposed that continued bonds with deceased loved
ones often provides comfort and facilitate coping, serving as a critical
element of grief adaptation rather than a symptom of poor mental
health (e.g., Asai et al., 2010; Klass et al., 1996; Klass & Steffen, 2018).
Stroebe and Schut (2005) suggested that positive reminiscing about the
deceased could in fact be interpreted as a sign of coming to terms with
grief. Field and Friedrichs (2004) found retaining bonds to be a positive
coping mechanism among widows whose spouses had died more than
two years ago. Foster et al. (2011) study among bereaved family mem-
bers reported that although continuing bonds were a source of distress
among a minority of parents and siblings, most experienced comforting
effects through reminiscing about, engaging in inner conversations with,
or sensing the presence of the deceased. Niemeyer, Baldwin, and Gillies
(2006) proposed that cases of negative adaptation were linked to the
nature of the relationship with the deceased as well as the ability of the
bereaved to make sense of the death.
Several researchers have highlighted religion and culture as salient factors
in the relationship between continuing bonds and healthy coping (e.g.,
Bray, 2013; Klass, 2006). In particular, strong continued bonds have been
associated with lower levels of distress over the long term in non-western
societies characterized by communal grieving rituals (Hussein & Oyobode,
2009; Suhail, Jamil, Oyebode, & Ajmal, 2011). For example, Suhail et al.
(2011) study of grief adaptation among Pakistani Muslims revealed that
participants’religion provided a basis for coping and adjustment through
dreaming and talking to the deceased, engaging in reminiscence, and
rationalizing and accepting the death.
Bonanno et al. (2005) compared bereavement coping strategies in the
United States and China, finding that whereas initial grief processing was
not a significant predictor of long-term distress or perceived health in
Chinese participants, in the United States, processing early in bereavement
was a strong positive predictor of long-term distress and poorer perceived
health even after accounting for participants’initial distress levels. Notably,
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 237
bereaved participants in the Chinese sample demonstrated more acute dis-
tress and poorer perceived health in the early months of bereavement than
those in the United States; however, the former showed greater improve-
ment over time and evinced less distress and similar levels of perceived
health as the U.S. sample by 18 months post-loss. They attributed the dif-
ference to contrasting cultural approaches to bereavement coping: whereas
mourning among westerners is typically aimed at “accepting the finality of
the death and overcoming the emotional pain of attachment,”Chinese grief
work emphasizes reinforcing cultural beliefs and continuing the relation-
ship with the deceased (Bonanno et al., 2005). In this context, the authors
found overall higher levels of reported deliberate grief avoidance across
time in the Chinese participants relative to the U.S. sample. However,
Burton et al. (2012) cross-cultural study of coping strategies in the U.S. and
China added coping flexibility (i.e., employing multiple coping and emotion
regulation strategies) as a variable and compared asymptomatic conjugally
bereaved individuals and married couples. They found that coping strat-
egies were similar within each subsample across cultures and that lower
coping flexibility was more associated with pathological grief regardless of
culture. Similarly, Taku, Cann, Tedeschi, and Calhoun (2009) study of
deliberate vs. intrusive rumination and post-traumatic growth among
Japanese and U.S. participants indicated that ongoing constructive rumin-
ation was associated with greater growth in both groups. Although there
were differences between the groups in terms of the post-event time peri-
ods when deliberate rumination was most significant for contributing to
post-traumatic growth, the authors suggested that these distinctions might
be attributable to differences between samples (e.g., mean age) rather than
sociocultural factors.
Despite the above, psychological distress remains a significant post-
bereavement mental health concern ( Boelen & Reijntjes, 2016;Pham
et al., 2018;Tsaietal.,2018), and such responses may be prolonged
and exacerbated in the presence of certain avoidant coping styles (Eisma
et al., 2017). However, a better understanding is needed of the relation-
ship between specific coping strategies, time post-loss, and psychological
distress. Specifically, it is unclear whether there are transitional points or
discernible changes in optimal coping strategies as the time post-
loss increases.
In an attempt to address the aforementioned gap, this study investigated
the relationship between bereavement coping strategies and self-reported
psychological distress as a function of time post-loss. Specifically, this study
sought to address the following research question: Do the relationships
between coping strategies and psychological distress change over time post-
bereavement?
238 T. UCHIDA ET AL.
Methods
Research design
This was a cross-sectional study entailing the administration of surveys at
two time points a year apart (September 2016 and September 2017). Due
to the difficulty of tracking bereaved families over a number of years, this
study recruited bereaved families experiencing various periods of bereave-
ment. Data collection was divided into two time periods to increase the
number of participants.
Measures
The questionnaire consisted of several closed-ended and free-response
items regarding services at the palliative care ward as well as two psycho-
logical scales. To gauge participants’psychological distress, this study used
the Japanese version of the Kessler Psychological Distress Scale (K6;
Furukawa et al., 2008. The K6 consists of six items measured on a 5-point
Likert scale (0–4). Higher scores indicate more severe psychological distress
(Kessler et al., 2003). The Japanese version of the K6 has been previously
validated with high discrimination between individuals with and without
psychological distress (AUC ¼0.94, 95% confidence interval ¼0.88–0.99;
Furukawa et al., 2008). A cutoff point of 9/10 has been used to screen for
mood or anxiety disorders (Sone et al., 2016; Suzuki, Fukasawa, Obara, &
Kim, 2014), and that was adopted in this study. Cronbach’s alpha for the
K6 was 0.89 as reported by Matsuoka et al. (2012). In this study, the
Cronbach’s alpha coefficient was 0.93.
The study also used the Coping with Bereavement Scale (CBS). The CBS
is a 14-item self-report measure designed to assess the strategies by which
Japanese individuals attempt to cope with loss. All items are scored on a 4-
point scale from 0 (disagree) to 3 (agree). The study by Sakaguchi,
Kashiwagi, and Tsuneto (2001) demonstrated a three-factor solution,
mapped onto the following methods of coping: (1) “Life orientation,”i.e.,
positive coping oriented to future life experiences; (2) “Avoidance,”a cop-
ing strategy that entails suppressing memories of the deceased; and (3)
“Retaining ties,”i.e., maintaining “continuing bonds”with the deceased
(Klass et al., 1996) Internal consistencies of the three components were
0.78, 0.78, and 0.70, respectively. In this study, the Cronbach’s alpha coeffi-
cients were 0.76, 0.79, and 0.77, respectively.
Sample and procedures
The study’s target sample was family members of individuals who died
from cancer in the palliative care unit of Tohoku University Hospital
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 239
(Sendai, Japan) from August 2013 to March 2016. During consultations
with presiding physicians while their family member was hospitalized, in
addition to information about a follow-up group program for families of
deceased patients, subjects were given a form to indicate consent to receive
the questionnaire survey via postal mail.
The first survey was conducted in September 2016 and targeted family
members of individuals who died in the palliative care unit of Tohoku
University Hospital from August 2013 to March 2015. The second survey
was carried out in September 2017 and targeted the family members of
individuals who died in the palliative care unit of Tohoku University
Hospital from April 2015 to March 2016. In cases when patients belonged
to multiple families, the individual who visited the patient most often while
they were hospitalized was asked to provide answers. Return of the ques-
tionnaire form via postal mail was deemed an expression of consent to par-
ticipate in this study. Of the 347 questionnaires sent, 173 were returned
with usable data. The response rate was 49.9%.
The research design for this study was approved by the Ethics
Committee of Tohoku University Graduate School of Medicine and
Tohoku University Hospital.
Analysis
Exploratory and confirmatory factor analysis were conducted for the 14
CBS items. Univariate analyses (t-test and one-way ANOVA) were used to
examine the relationship between CBS subscale scores and respondent
characteristics and K6 scores and respondent characteristics. In addition,
Pearson’s correlations between CBS subscale scores and K6 scores stratified
by time post-loss were calculated to investigate the relationship between
psychological distress and coping strategies. Statistical analyses were con-
ducted with IBM SPSS statistical software and AMOS, version 20.0 (IBM
Japan, Tokyo, Japan). All testing was two-tailed, and the significance level
was set at a¼0.05.
Results
Demographic characteristics and K6 scores
Demographic characteristics of the participants are shown in Table 1. The
majority of participants were female (62.3%) and were spouses or partners
of the patient/deceased (60.4%). Additionally, the majority were within two
years post-loss (83.6%).
The mean K6 score was 6.44 (SD ¼5.88), and 44 participants (27.0%)
had scores higher than the cutoff point (>9) for the detection of
240 T. UCHIDA ET AL.
depressive disorder. Spouses of the deceased tended to report greater psy-
chological distress than did children or those reporting other relationships.
However, there were no significant differences in psychological distress
between genders, age groups, or time post-loss.
Factor analysis for the CBS
The confirmatory factor analysis was conducted for the 14 CBS items. In
reference to Sakaguchi et al. (2001), the factor structure was set up with
“Life Orientation,”“Avoidance,”and “Retaining Ties”as distinct factors.
Table 2 shows estimated factor loadings for each question item and
Table 1. Demographic characteristics and K6 scores (N¼173).
K6 scores
n(%) MSD t F p
Age (years)
Under 40 s 25 (14.7) 4.96 4.88 1.16 .33
50 s 37 (21.8) 5.86 6.27
60 s 65 (38.2) 6.72 5.48
Over 70 s 43 (25.3) 7.59 6.75
Sex
Male 61 (37.7) 5.86 5.46 1.06 .29
Female 101 (62.3) 6.89 6.11
Relationship
Spouse 102 (60.4) 7.74 5.97 5.95 .00**
Child 45 (26.6) 4.82 5.26
Other 22 (13.0) 4.05 5.50
Period after bereavement
Less than 1 year 63 (36.8) 6.85 6.43 .33 .72
One year to less than 2 years 80 (46.8) 6.05 4.84
Two or more years 28 (16.4) 6.70 7.33
Note. SD: standard deviation.
Other include siblings, son-in-law, daughter-in-law, and relatives.
p<.01.
Table 2. The confirmatory factor analysis for the coping with bereavement scale (n¼160).
Items I II III
1 I encouraged myself to carry on without the deceased. .71
2 I tried to live for the deceased, as well. .81
3 I decided it was not the time to get depressed. .49
4 I made my daily life my ultimate priority. .34
5 I found purpose in living. .64
6 I thought about the rest of my life. .54
7 I would avoid thinking about the deceased. .86
8 I would forget about the deceased. .76
9 I would not speak about the deceased. .72
10 I acted as if nothing happened. .50
11 I reflected on the words and gestures of the deceased. .76
12 I talked with the deceased in my mind. .80
13 I often visited the deceased’s grave and places that held
fond memories of the deceased.
.68
14 I carried around photographs and personal effects of the deceased. .56
Cronbach (a) .76 .79 .77
Factor correlation I .01 .47
II .52
III
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 241
correlations between factors. The model’s goodness of fit indices were
v
2
(74) ¼174.78, p<.001, GFI¼.86, AGF ¼.80, CFI¼.87, and RMSEA＝
.09. Although they did not reach the recommended level (Hu & Bentler,
1999), in order to maintain comparability with Sakaguchi et al. (2001),
these reference values were treated as acceptable ranges. All items had a
salient loading (>.30), and the acoefficient attained a sufficient value for
all factors.
Comparison of CBS scores
The mean (SD) of the “Life Orientation”“Avoidance,”and “Retaining
Ties,”was 11.53 (3.85), 7.86 (3.14), and 2.42 (2.55), respectively. Females
(M¼8.35, SD ¼3.01) of the deceased tended to report “Retaining ties”to a
greater extent than did males (M¼6.90, SD ¼3.16; t[156] ¼2.88, p<.01).
Spouses (M¼8.36, SD ¼3.04) of the deceased tended to report “Retaining
ties”to a greater extent than did children (M¼7.11, SD ¼2.98) or those
reporting on other relationships (M¼6.90, SD ¼3.43; F[2, 162] ¼3.67,
p<.05). Meanwhile, no significant difference according to age or Period
after bereavement was indicated for “Retaining ties.”Moreover, no differ-
ence due to Demographic Characteristics was found for “Life Orientation”
or “Avoidance.”
Correlation between psychological distress and coping with bereavement
Retaining ties scores were correlated with psychological distress overall and
this was the strongest for respondents testing 2 or more years after their
loss (r¼.11 at half a year to less than 1 year, r¼.17 at 1 year to less than
2 years, r¼.64 at 2 years or more) (Table 3). In fact, the only statistically
significant findings were for participants who completed the measures two
years or more post-loss.
To remove the effect of sex or relationship on these correlations, partial
correlation analysis was conducted for all participants and found no notice-
able differences between the result of the partial and the usual correlation
analysis. Upon carrying out a v
2
test for all three periods after bereavement
for gender, age, and relationship bias, no statistically significant biases were
found. Further, no significant relationship was observed between period
after bereavement and age.
Discussion
The purpose of the present study was to investigate the relationship
between bereavement coping strategies and self-reported psychological dis-
tress as a function of time post-loss. It was found that individuals who
242 T. UCHIDA ET AL.
Table 3. Pearson correlation of psychological distress and coping with bereavement within the period after bereavement.
K6 score
Total (n¼165) At less than 1 year (n¼63) At 1 year to less than 2 years (n¼80) At 2 or more (n¼28)
r(95%CI) pr(95%CI) pr(95%CI) pr(95%CI) p
Coping with bereavement
Life Orientation .05 (.20—.10) .52 .05 (.29—.20) .70 .14 (.35—.08) .25 .09 (.45—.29) .66
Avoidance .01 (.16—.14) .97 .03 (.28—.22) .82 .03 (.25—.19) .77 .01 (.38—.36) .96
Retaining Ties .25 (.10—.39) .00** .15 (.10—.38) .24 .17 (.05—.37) .15 .64 (.35—.82) .00**
p<.01.
Bolded values represent P-values significant at alpha ¼0.05.
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 243
were more than 2 years post-loss and reported stronger tendencies to retain
ties with the deceased also reported greater psychological distress.
Individuals who did not have proactive daily life orientations reported
greater psychological distress. Avoidance was not significantly correlated
with psychological distress.
Bereavement is strongly associated with increased incidence and severity
of depression and other mental health concerns (Boelen, 2013; Tsai et al.,
2018). According to the cutoff point for the Japanese version of the K6, 44
participants (27.0%) were suspected to have psychological distress, includ-
ing potential depression. However, the likelihood of experiencing this level
of psychological distress was not associated with time post-loss. These
results are similar to those of previous studies showing that more than
one-third of bereaved family members met the criteria for psychological
distress at six months post-death and 29% of bereaved family members met
the criteria at 13 months post-death (Thomas, Hudson, Trauer, Remedios,
& Clarke, 2014). Therefore, it seems unlikely that psychological (mal)adap-
tation to bereavement occurs simply as a function of time post-loss; rather,
it seems likely that it is influenced by a number of internal and external
factors. With respect to internal factors, respondents’engagement with
various coping methods was quantified using the CBS. The present factor
analysis agreed with a previous three-factor solution comprised of “Life ori-
entation,”“Avoidance,”and “Retaining ties”(Sakaguchi et al., 2001).
“Retaining ties”refers to concepts such as “continuing involvement with
the deceased,”“feeling a bond with the deceased,”and “sense of connection
with the deceased”(Bonanno et al., 2004; Shaver & Tancredy, 2001), and
this coping style is thought to be an important component for understand-
ing the psychological adaptation of bereaved family members. Retaining
ties, which has been linked to rumination in previous studies, is often asso-
ciated with poorer mental health outcomes, similar to those observed here
(Eisma et al., 2014a,2017). In contrast, “avoidance”has traditionally been
viewed as a maladaptive coping style for bereavement (Raphael, 1983).
Notably, Currier, Irish, Neimeyer, and Foster (2015) found a strong associ-
ation between avoidance and complicated grief among participants with
high levels of continuing bonds with the deceased. However, other studies
have suggested that avoiding unpleasant emotions as a coping style during
bereavement is not necessarily maladaptive (Bonanno, Keltner, Holen, &
Horowitz, 1995; Fraley & Bonanno, 2004). Rather, as Fraley and Bonanno
(2004) demonstrated, whereas fearful avoidance can negatively influence
the ability to adapt to loss, dismissing avoidance—i.e., redirecting one’s
attention away from negative experiences (Fraley, Davis, & Shaver, 1998)
was associated with resilience. Our findings agree with this interpretation,
as avoidance was not correlated with psychological distress via the K6. It is
244 T. UCHIDA ET AL.
possible that for some individuals, short-term use of purposeful distraction
may be a strategy in response to depression (Nolen-Hoeksema & Morrow,
1993). Furthermore, Stajduhar, Martin, and Cairns (2010) suggested that a
positive outlook on life is associated with longer-term psychological well-
being post-bereavement.
More importantly, the results revealed that bereaved individuals who
retained strong ties with the deceased 2 or more years following bereavement
demonstrated poorer mental health. Although retaining ties with the deceased
may be an adaptive psychological process shortly after bereavement
(Bonanno et al., 2004; Carnelley et al., 2006;Shaver&Tancredy,2001), found
was that persistence in this coping strategy for 2 years or more was moder-
ately associated with greater psychological distress. Previous studies found
that bereaved individuals who retained ties with the deceased demonstrated
poorer mental health (Boelen, Stroebe, et al., 2006;Eismaetal.,2014a,2015;
Field et al., 2003; Scholtes & Browne, 2015). While a plausibly natural
response to loss in the short-term sample evidence, including the present
findings, other research has repeatedly demonstrated the potential for nega-
tive mental health outcomes in the long-term for individuals who engage in
more prolonged ruminative coping behaviors (Eisma et al., 2014a,2017).
Indeed,Fieldetal.(2003), identified a correlation between higher grief scores
and strong continued bonds 5 years after the loss. However, another study
indicated that associations between continued bonds and psychological dis-
tress among widows who had been bereaved for more than 2 years were less
consistent (Field & Friedrichs, 2004).
These findings require further corroboration, as well as more detailed infor-
mation regarding how current life events and other factors such as social sup-
ports or religious or spiritual beliefs may contribute to psychological distress
to fully uncover the nature of the relationship between retaining ties to the
deceased and K6 scores long after bereavement (Bray, 2013; Hussein &
Oyobode, 2009; Suhail et al., 2011). Similarly, it is also important to examine
the role of other factors in contributing to this relationship. Neimeyer,
Baldwin, and Gillies (2006) emphasized the significance of the relationship
between the bereaved and the deceased and the nature of the death role in
impacting the level of psychological distress and highlighted the role of sense-
making as a moderator of complicated grief symptoms among those with high
levels of post-loss attachment. Stroebe and Schut (2005) suggested that retain-
ing ties was more likely to be detrimental in cases of problematic ties during
the lifetime of the deceased, as such bonds tend to be more insecure, depend-
ent, or conflicted. Future studies should consider collecting more information
on relationships between the deceased and their bereaved family members.
This study’s findings are also notable due to cross-cultural similarities
between the Japanese sample and samples in other socio-cultural contexts.
JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 245
In Japan, widely accepted practices such as regular cemetery visits, holding
on to the deceased’s belongings, and making offerings at the family altar
might be associated with different psychological outcomes relative to west-
ern societies (Asai et al., 2012). Asai et al. (2012) hypothesized that their
Japanese sample would evince results similar to those in Chinese and other
East Asian societies, whereby “avoidance”has been found to have no effect
on psychological states and “continuing bonds”had a reduced effect.
Notably, they found that these strategies had more complex effects than
expected, as avoidance and continuing bonds had both adaptive and mal-
adaptive aspects. However, they did not examine the influence of time
post-loss on psychological outcomes. The authors of this study suggest that
in the context of this study, “retaining ties”is an effective short-term cop-
ing mechanism; however, such culturally-embedded attachments to the
deceased are potentially harmful over the long term. Further research is
needed to clarify cross-cultural similarities and differences in the impacts
of this and other ruminative coping strategies.
This study has several implications for social work practice.
Professionals need to be aware that whereas “retaining ties”can be effect-
ive in the short term, maintaining such linkages over a prolonged period
can be detrimental to the bereaved. Professionals also need to account
for the time post-loss when devising strategies to counsel bereaved indi-
viduals and families. In addition, although cross-cultural effects remain
inconclusive, professionals may need to consider cultural factors such as
communal grieving and deliberate avoidance, which have been demon-
strated to have positive effects on grief recovery in many non-western
societies (e.g., Asai et al., 2012; Bonanno et al., 2005; Suhail et al., 2011).
Effective social work practices may include life-oriented support to help
bereaved individuals avoid social isolation and discover a new purpose or
meaning in their lives.
There are several limitations in this study that must be acknowledged.
First, the sample was limited to willing respondents from a narrow popula-
tion (bereaved family members of patients at a specific palliative care facil-
ity in Japan) and the study’s sample size, particularly regarding those two
or more years into coping with their loss, were relatively small. A larger
sample size, including a wider array of manners of death and pre-loss care
(e.g., those with sudden loss without palliative care) would provide more
generalizable information about the relationship between bereavement cop-
ing methods and mental health among bereaved individuals. Secondly, this
study employed a cross-sectional approach –therefore, the results require
careful interpretation. It is essential to clarify changes over time in more
detail in future longitudinal studies. Finally, a general mental health screen-
ing tool was used to quantify post-loss mental health outcomes. Future
246 T. UCHIDA ET AL.
studies should examine specific grief symptoms and precise mental health
outcomes, such as depression and anxiety.
Conclusion
In conclusion, bereaved individuals who retained strong ties with the
deceased, even after 2 years, demonstrated poorer mental health. However,
these associations were not identified in individuals who had undergone
more recent loss. Future work identifying optimal coping mechanisms that
are sensitive to the evolving needs of the bereaved as time-since-loss
increases is critical for identifying individuals at risk for poorer long-term
bereavement-related outcomes, as well as for developing and initiating early
interventions to assist these individuals.
Acknowledgment
We would like to thank Editage (www.editage.com) for English language editing.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This research was partly supported by a Grant-in-Aid for Scientific Research (C) from the
Japan Society for the Promotion of Science under Grants 15A04108 and 18K03086.
Data availability statement
The data that support the findings of this study are available on request from the corre-
sponding author, TU. The data are not publicly available due to ethical restrictions.
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