A review of the research on conjugal bereavement: impact on health and efficacy of intervention

Behavioral Activation and Therapeutic Exposure vs. Cognitive Therapy for Grief Among Combat Veterans: A Randomized Clinical Trial of Bereavement Interventions

Approximately two-thirds of Operations Enduring Freedom, Iraqi Freedom, and New Veterans reported knowing someone who was killed or seriously injured, lost someone in their immediate unit, or personally saw dead or seriously injured Americans (Hoge et al., 2004; Thomas et al., 2010; Toblin et al., 2012). Thus, it is not surprising that prevalence of Persistent Complex Bereavement Disorder (PCBD) is high in these groups. Importantly, PCBD impact appears to be independent of both Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (Bonnano, 2007), 2 disorders that are also highly prevalent in these groups, thus tailored treatments for grief are indicated. The Department of Veterans Affairs suggests Cognitive Therapy for Grief as a first line psychotherapy, however treatments relatively more focused on behavior change and exposure to grief cues also may be useful for this population. To address this question, the present study used a randomized controlled trial to compare a 7-session program of Behavioral Activation and Therapeutic Exposure for Grief vs. Cognitive Therapy for Grief among 155 OIF/OEF/OND veterans. Both treatments produced significant treatment gains over baseline, and these improvements were maintained over 6-month followup; however no differences were observed between groups. Given equal efficacy, implications for matching treatment to patient characteristics are discussed.

A new conception and subsequent taxonomy of clinical psychological problems

BACKGROUND

A taxonomy of the objects of study, theory, assessment, and intervention is critical to the development of all clinical sciences. Clinical psychology has been conceptually and administratively dominated by the taxonomy of an adjacent discipline - psychiatry's Diagnostic and statistical manual of mental disorders (DSM). Many have called for a 'paradigm shift' away from a medical nosology of diseases toward clinical psychology's own taxonomy of clinical psychological problems (CPPs), without being able to specify what is to be listed and classified.

MAIN TEXT

An examination of DSM's problems for clinical psychology, especially its lack of clinical utility, and a search for the essence of CPPs in what clinical psychologists actually do, leads to the proposal that: The critical psychological-level phenomenon underlying CPPs is the occurrence of 'problem-maintaining circles' (PMCs) of causally related cognitions, emotions, behaviours, and/or stimuli. This concept provides an empirically-derived, theory-based, treatment-relevant, categorical, essentialist, parsimonious, and nonstigmatizing definition of CPPs. It distinguishes psychological problems in which PMCs have not (yet?) formed, and which may respond to 'counseling', clinical psychological problems in which active PMCs require clinical intervention, and psychopathological problems which are unlikely to be 'cured' by PMC-breaking alone.

CONCLUSION

A subsequent classification and coding system of PMCs is proposed, and expected benefits to research, communication, and the quality of case formulation in clinical psychology are described, reliant upon a development effort of some meaningful fraction of that which has been devoted to the DSM.

Does Mutual Help Facilitate Newly Bereaved Widowers?

Studies have demonstrated the efficacy of mutual-help interventions for bereaved women, but there have been no controlled intervention studies of this type for men. The objective of this study was to assess the efficacy of a mutualhelp group intervention for new widowers, using a randomized controlled design. A community sample of 113 recruited widowers bereaved less than 12 months were randomly allocated into treatment (n = 61) and waitinglist control groups (n = 52). Treatment consisted of nine weekly semistructured peer group sessions, which focused on the griefprocess, diet, new relationships, exercise, and life-style issues. Analysis of variance of three psychological measures (GeneralHealth Questionnaire, Beck Depression Inventory, State-Trait Anxiety Inventory) and three social measures (Social Adjustment Scale, Social Support Questionnaire for both availability and satisfaction) showed significant improvement over time for all subjects, but no significant differences between the two groups over the observation period (baseline to 8 months). Possible reasons for no treatment effect include: men may take longer than anticipated to work through their grief with a delay in any measurable effect; the more recovered men dropped out early; and focusing widowers' attention on their own and others'grief may hinder an early (and measurable) recovery from their grief

Survivors of Homicide: Mental Health Outcomes, Social Support, and Service Use Among a Community-Based Sample

This study aims to explore rates of bereavement-related mental health outcomes and diagnostic comorbidity along with the associations between mental health outcomes, perceived social support, knowledge of services, and service use among a diverse sample of 47 survivors 2 years post loss. Findings are consistent with prior studies in that homicide is associated with an overlapping of significant symptom presentation of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and complicated grief (CG). Lack of grief-specific social support was demonstrated to be associated with PTSD and MDD but not with CG. Although a significant number of survivors reported poor mental health outcomes, a limited number were using services.

Online Grief Support Communities

Online grief support communities have become popular in recent years for those seeking information and empathetic others following the death of someone close to them. Hundreds of Facebook pages and Web sites are now devoted to bereavement—and health-care professionals need to assess what therapeutic benefits virtual communities might offer to help people manage grief and integrate death into their lives. In the current study of online grief support networks ( N = 185), individuals report less psychological distress as a result of joining these groups—and this psychosocial benefit increased over time. Individuals who were members for a year or more characterized their grief as less severe compared with those who had a shorter tenure in the community. Additional findings and implications are discussed.

Grieving: the role of self-reorganization

Grieving is a well-known topic to psychodynamic clinicians. Nonetheless, the identity disturbance and identity growth issues that accompany the familiar problems are less well known. Phases of modification of self-organization during an adaptive mourning process can be facilitated by helping patients with pathological grief clarify the shifts they are experiencing in self-state and self-concepts.

Interventions for spousal bereavement in the older adult: an evidence review

The loss of a spouse is a significant psychological and physical health issue for older adults, the fastest growing age group in the United States. A search was performed to review publications over the last 20 years examining the effect of interventions on grieving processes for older bereaved spouses. Nine publications met inclusion criteria and were critically reviewed. Study designs, populations, and outcomes measured varied widely. All intervention types showed improvements in grief-related outcomes, but statistical significance of major measures between interventions and controls was absent in all but one study using a mind-body intervention. Recommendations for future studies include testing of secondary and tertiary bereavement types and categorizing grief patterns in study populations.

Behavioral activation and therapeutic exposure for bereavement in older adults

The development and clinical trial of a 5-session behavioral intervention for complicated bereavement (CB) is presented. We conceptualized CB in terms of Major Depression (MDD) and Post-traumatic Stress Disorder (PTSD) and consequently applied treatment components of Behavioral Activation and Therapeutic Exposure (BA-TE). In order to assure standardization of treatment, control costs, and engage patients, a multi-media, multi-context format was adopted to address avoidance and withdrawal behaviors conceptualized as central pathogenic responses in CB. Participants (N = 26) were assessed before and after BA-TE treatment via structured clinical interview and standardized questionnaires in terms of PTSD, MDD, CB, and health concerns. The number of days since the death of the loved one was widely variable and served as a covariate for all outcome analyses. ANCOVAS revealed statistically significant improvement, irrespective of how many days since death had elapsed prior to initiation of intervention, on structured interviews and self-report measures for most outcome variables.

Depression, anxiety and quality of life in suicide survivors: a comparison of close and distant relationships

The study's purpose was to describe and compare depression, anxiety, and quality of life, by degree of relationship, between closely related and distantly related survivors (persons close to the suicide victim, or "suicide survivors"; N = 60) during the acute phase of bereavement (within 1 month of the death). The close relationship category included spouses, parents, children, and siblings, whereas the distant relationship category included in-laws, aunts/uncles, and nieces/nephews. Analysis of covariance examined differences between the two groups on the symptom measures. Results indicate that, after controlling for age and gender effects, closely related survivors had significantly higher mean levels of depression and anxiety and had lower levels of mental health quality of life. There were no statistically significant differences on the physical health quality of life subscale.

Physiological and psychological symptoms of grief in widows

In this cross-sectional descriptive survey of 173 widows, we describe their grief symptoms using an open-ended questionnaire and the Revised Grief Experience Inventory. Self-reported physical symptoms included pain, gastro-intestinal problems, medical/surgical conditions, sleep disturbances, and neurological/circulatory issues. Psychological symptoms were reported as depression, anxiety, and loneliness. The mean total grief score was 71.4 +/- 30.2 (possible range 22-132). Physical symptoms were significantly correlated with the total mean grief score, and subscales of physical distress, depression, existential tension, and guilt. When the subjects were grouped by years since loss, (range 1-5 years), there was no significant decrease found in overall grief scores, suggesting symptoms of grief experienced by widows may continue up to at least 5 years.

Grief and its complications in individuals with intellectual disability

Bereavement and loss have significant impact on the lives of individuals with intellectual disability (ID). Although there is a growing impetus to define the symptoms of grief that predict long-term functional impairment, little is known about maladaptive grieving among individuals with ID. We examine the literature concerning the phenomenology of traumatic grief (TG) in the general population, along with what is known about the manifestations of grief in individuals with ID. We then apply modern theories of grief and grief resolution to individuals with ID in order to highlight potential areas of vulnerability in this population and to lay the groundwork for interventions that will facilitate their adaptation to loss. We provide a theoretical framework for the proposition that individuals (including children and adults) with ID are more susceptible to TG, based on an increased risk of secondary loss, barriers to communicating about the loss, and difficulty finding meaning in the loss. We conclude that individuals with ID should be considered as potential candidates for targeted bereavement interventions. Further research is required, however, in order to develop population-appropriate measurement scales for testing these hypotheses.

Treatment of complicated grief: a randomized controlled trial

CONTEXT

Complicated grief is a debilitating disorder associated with important negative health consequences, but the results of existing treatments for it have been disappointing.

OBJECTIVE

To compare the efficacy of a novel approach, complicated grief treatment, with a standard psychotherapy (interpersonal psychotherapy).

DESIGN

Two-cell, prospective, randomized controlled clinical trial, stratified by manner of death of loved one and treatment site.

SETTING

A university-based psychiatric research clinic as well as a satellite clinic in a low-income African American community between April 2001 and April 2004.

PARTICIPANTS

A total of 83 women and 12 men aged 18 to 85 years recruited through professional referral, self-referral, and media announcements who met criteria for complicated grief.

INTERVENTIONS

Participants were randomly assigned to receive interpersonal psychotherapy (n = 46) or complicated grief treatment (n = 49); both were administered in 16 sessions during an average interval of 19 weeks per participant.

MAIN OUTCOME MEASURE

Treatment response, defined either as independent evaluator-rated Clinical Global Improvement score of 1 or 2 or as time to a 20-point or better improvement in the self-reported Inventory of Complicated Grief.

RESULTS

Both treatments produced improvement in complicated grief symptoms. The response rate was greater for complicated grief treatment (51%) than for interpersonal psychotherapy (28%; P = .02) and time to response was faster for complicated grief treatment (P = .02). The number needed to treat was 4.3.

CONCLUSION

Complicated grief treatment is an improved treatment over interpersonal psychotherapy, showing higher response rates and faster time to response.

What helps middle-aged widows with their psychological and social adaptation several years after their loss?

This study examines the factors contributing to middle-aged widows' adaptation to their husbands' death due to physical illness, 1 to 5 years after the initial loss. Ninety-three widows and 93 married women, who served as controls, filled out questionnaires assessing their experience of stress and strain, their Sense of Coherence level, the social support they received, as well as measures of psychological and social adaptation. Results show that several years after their husbands' death, many widows still perceive life events and hassles as significantly more intense experiences than do their married counterparts. Moreover, they report a significantly lower Sense of Coherence, diminished social support and a lower level of mental health, as compared with married women. Multiple regression revealed that Sense of Coherence was the most significant contributor to adaptation variables, especially to mental health. Social support contributed significantly to the 2 social adaptation subscales. The discussion emphasizes the importance of Sense of Coherence to adaptation

The Relation of Locus of Control and Social Support to Life-Cycle Related Needs of Widows

This study is a part of a larger research project on the coping of widows. The study reported here investigated the effects of widowhood-related needs along the life-cycle and variables hypothesized to be related to it, using a multivariate hierarchical regression model. The participants were 246 widows who were sampled by stratified-random sampling, according to age groups, from the population of social insurance recipient Israeli urban widows. The findings indicate that personal resource variables—age and locus of control orientation—were directly related to the four need constellations studied. Two of the three social support variables studied—size of the network and likelihood of seeking help from network members—were related to the needs only when interacting with the personal variables. The findings support previous research regarding the role of locus of control as a support mobilizer, and point to the importance of including personal as well as environmental resources, such as social support, in the study of bereavement and coping.

The link between response styles and major depression and anxiety disorders after child-loss

Although several studies have indicated that persons with a high ruminative coping style experience higher depression after the loss of a loved one, the relationship between ruminative coping and the occurrence of clinical depression and anxiety disorders after a loss has not been thoroughly investigated. This study investigated the relationship between response styles (ruminative coping v distractive coping) and the onset of major depression and anxiety disorders in a sample of parents who had experienced sudden child-loss (N = 106). The incidence of major depression after the loss of a child was very high (69%). After controlling for demographic variables and psychiatric history, ruminative coping was significantly associated with the onset of major depression, as defined by DSM-IV, but not with the onset of anxiety disorders. Thus ruminative coping after the loss of a child appears to be a risk factor specifically for major depression.

The syndrome of traumatic grief

Traumatic grief is a common and debilitating syndrome whose clinical presentation is well recognized but whose diagnostic criteria have only recently been delineated. Though it shares features with major depressive disorder, adjustment disorder, and posttraumatic stress disorder, none of these subsume the criteria set for traumatic grief, and the diagnostic overlap is limited in community samples. Furthermore, diagnosis of traumatic grief appears to have prognostic value for clinical course and treatment response among bereaved individuals. In the absence of empirically supported treatments of pathological grief, a new, manualized treatment for traumatic grief symptoms has been developed and is currently undergoing testing in a randomized controlled trial. The conceptual basis for Traumatic Grief Treatment (TGT) is presented, the structure of the treatment is outlined, and the primary clinical strategies employed are described.

The contribution of small life events to the psychological distress of married and widowed older women

The contribution of small life events to the prediction of general psychological distress was examined for 50 married and 21 recently widowed older women. These two groups were contrasted as having or not having experienced an uncontrollable major life stressor (i.e., the recent death of a spouse). Negative small life events (i.e., daily hassles) contributed above and beyond general demographic factors; conjugal bereavement status; social support; other, non-conjugal bereavement, major life events; and the interaction of these life events and social support in the prediction of general psychological distress. Results support assessing negative small life events as well as major life events for both married and recently widowed older women.

Impact of cadaveric organ donation on Taiwanese donor families during the first 6 months after donation

OBJECTIVE

Organ donation is a complex decision for family members of Asian donors. The impact of cadaveric organ donation on both Chinese and Western donor families has not been well investigated within a cultural framework. The purposes of this study were to follow Chinese family members' appraisal of their decision to donate organs, to explore the possible negative and positive impacts of organ donation on their family life, and to determine what help they expected from healthcare providers during the first 6 months after donation.

METHODS

Twenty-two family members (10 men and 12 women) of cadaveric organ donors who signed consent forms at an organ transplant medical center in Taiwan participated in this project and completed in-depth interviews during the sixth month after donation.

RESULTS

Participants were 25 to 56 years old (mean = 48.15 +/- 8.31 years). The type of kinship of the participants included the donor's parents, older sister, and spouse. Subjects reported several negative impacts: worry about the donor's afterlife (86%), stress due to controversy among family members over the decision to donate (77%), and stress due to others' devaluation of the donation (45%). Positive impacts reported by the subjects included having a sense of reward for helping others (36%), having an increased appreciation of life (32%), having closer family relationships (23%), and planning to shift life goals to the study of medicine (9%). Subjects expected the transplant team to provide information about organ recipients (73%), to submit the necessary documents so that family members could receive healthcare payments from the insurance company (68%), to help resolve legal proceedings and settlements associated with accidents (64%), and to not overly publicize their decision to donate (64%).

CONCLUSIONS

Although all of the subjects reported that organ donation was the right decision, the decision to donate did not protect Taiwanese donor families from negative psychocognitive bereavement. The impacts of organ donation were affected by the subject's social cultural, spiritual, and legal context and the nature of their bereavement.

Longitudinal course and predictors of continuing distress following critical incident exposure in emergency services personnel

This study examines the longitudinal course and predictors of stress-specific and general symptomatic distress in emergency services personnel. A three-group quasi-experimental design was used to determine the responses of 322 rescue workers to the Loma Prieta earthquake Interstate 880 Freeway collapse and to unrelated control critical incidents. Self-report questionnaires, including measures of incident exposure, peritraumatic dissociation and emotional distress, and current symptoms, were administered 1.9 years (initial) and 3.5 years (follow-up) after the freeway collapse. Despite modest symptom improvement at follow-up, rescue workers were at risk for chronic symptomatic distress after critical incident exposure. Peritraumatic dissociation accounted for significant increments in current posttraumatic stress disorder symptoms, over and above exposure, adjustment, years of experience, locus of control, social support, and general dissociative tendencies. The results suggest that rescue workers, particularly those with more catastrophic exposure and those prone to dissociate at the time of the critical incident, are at risk for chronic symptomatic distress.

Loss, grief, and bereavement in family members of cancer patients

OBJECTIVES

To review loss, grief, and bereavement related to family caregivers of cancer patients during illness and after death, and to review interventions to enhance survivors' recovery after the patient's death.

DATA SOURCES

Review articles, research studies, book chapters, and data from authors' research.

CONCLUSIONS

Loss and grief can lead to positive outcomes in survivors of patients who have died of cancer. Conversely, negative bereavement outcomes may put survivors at risk for illness and even death.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can provide interventions for family members that may positively influence physical health as well as recovery from bereavement. Outcomes research is needed to expand our understanding about how interventions affect survivors' recovery from bereavement.

Mind-body medicine in primary care. Implications and applications

A growing body of research in basic and clinical science confirms that psychological states and interventions affect physiologic and pathophysiologic processes and the outcome of clinical illness. This evidence is reviewed in detail, with special attention paid to those findings that have particular relevance for primary care physicians. Specific guidelines are offered for incorporating mind-body principles and techniques into primary care practice.

Family response to out-of-hospital death

OBJECTIVE

To better understand the perceptions, needs, and responses of family members after an out-of-hospital death.

METHODS

Over an 18-month period, phone interviews were conducted using a structured interview schedule modified from a similar study of survivors of in-hospital death. Subjects included 31 survivors of urban out-of-hospital deaths attended by paramedics from one ambulance company. Subjects were eligible if paramedics had arrived and death had been determined at the scene without transport. Survivors were interviewed 11 to 15 months after the death (mean = 12 months) to evaluate how well they coped with their loss, how they managed the experience of their loved ones' out-of-hospital deaths, and their feelings and beliefs about their loved ones' not being transported to a hospital.

RESULTS

None of the survivors believed their loved ones should have been transported to a hospital, and only one believed that something more could have been done for the individual. Although many of the survivors had suspected their loved ones had died, 64% had been informed of the death by emergency medical technicians (EMTs) or firefighters. Most thought the EMTs had informed them in a professional (81%) and gentle/supportive manner (74%). Some (29%) still had unanswered questions about the death, but most (58%) were adjusting well and no one had a "poor" adjustment.

CONCLUSION

In this small sample, survivors of out-of-hospital death were generally satisfied with the care their loved ones had received. None of the survivors believed their loved ones should have been transported to the hospital. They also believed the paramedics had been supportive and met their needs at the time of death. It appears that paramedics may be able to meet the needs of a patient's survivors by terminating out-of-hospital resuscitation efforts on the patient.

Exploring Widows' Experiences After the Suicide of Their Spouse

1. The widow of a spouse who committed suicide must cope with issues related to depression, anger, blame, guilt, and the stigma associated with suicide that makes recovery from this type of loss different for the survivors. 2. The predominant need of widows and widowers of suicide victims was to talk in an environment of acceptance and understanding, which could only be provided by other people who have had the same kind of experience. 3. There is no precise formula that exists to guide caregivers when assisting survivors of suicide victims, however suggestions include communicating with compassion; demonstrating care and concern; accepting the individual's grief; and offering and providing information.

Personality and Conjugal Bereavement in Older Widow(er)s

This study examined the degree to which an individual's propensity to experience emotional distress and restraint are predictive of grief intensity in a sample of older widow(er)s ( N = 51). Characteristic distress was found to be a significant predictor of present grief intensity, whereas repressive defensive-ness was found to predict past grief, as recalled from the time of loss. Results are discussed in light of known risk factors for complicated bereavement and intervention concerns.

Integrated psychotherapy for the elderly

The complexity of interacting variables in the geriatric patient imposes the therapeutic necessity to employ all effective therapeutic modalities in an interactive and integrated fashion. This paper examines the efficacy data on brief and longer term therapies as applied to the elderly, most particularly for treatment of depression and bereavement. In determining the development of an integrated psychotherapy treatment plan, the author suggests a decision pathway which incorporates concurrent utilization of theoretical principles derived from psychodynamic, interpersonal and cognitive behavioural theory. This tripartite approach informs the assessment and diagnosis of the patient as well as the specific choice of therapy. Directions for further research are suggested.

Effects of membership in bereavement support groups on adaptation to conjugal bereavement

Examined the contribution of membership in bereavement support groups (BSGs) to bereavement adaptation in a sample of 127 widows and widowers, 37 of whom participated in BSGs, during the first 18 months of their bereavement. Both BSG members and nonmembers exhibited significant declines in depression, anger, anxiety, subjective stress, and psychotropic medication usage over the 18-month course. Multiple regression analyses revealed that neither group membership nor level of group involvement was associated with significantly greater declines in these variables, after demographic variables, initial levels of distress, and levels of perceived social support were accounted for. In further exploratory analyses, however, the number of BSG meetings attended accounted for significant amounts of variance in levels of anger and psychotropic medication usage and interacted with perceived social support in accounting for variance in subjective stress. The extent to which these findings call into question common assumptions regarding the efficacy of BSGs and implications for future research are discussed.

A shortened version of an instrument measuring bereavement

The purpose of the study was to develop a tool to measure the grief experience. The Grief Experience Inventory (GEI) [Sanders et al., A Manual for the Grief Experience Inventory. C. M. Sanders, Charlotte, NC (1979)] was revised according to the Parkes [Bereavement: Studies of Grief in Adult Life. International Universities Press, New York (1972)] framework. Four hundred and eighteen subjects who had been primary care givers for significant others prior to the loss of the person through death completed Revised Grief Experience (RGEI) questionnaires. The internal consistency reliability (coefficient alpha) for the RGEI was 0.93. A principal components factor rotation was performed yielding a four factor solution consistent with the theoretical structure (Parkes, 1972). Results demonstrated that the RGEI is a concise, valid, and reliable measure sensitive to the grief experience.

A model of mourning: change in schemas of self and other

The mourning process may serve an evolutionary purpose, one that has allowed maximum survival characteristics. By passage through the phases of grief, the bereaved person prepares to make new commitments to others and to accept new personal roles. This passage involves an unconscious change in mental structures of meanings about the self and other people. This paper examines mourning in terms of such person schemas.

The relation of widows' needs and resources to perceived health and depression

The study investigated the relationship of widowhood-related needs and resources to physical health and to depressed affect. Participants were 246 widowed women of all ages, who were widowed from 1 to 7 years, and who were drawn by stratified-random sampling from widows living in urban areas in Israel, and receiving social insurance payments. The findings show that although there was a significant added contribution by resources, the unique contribution of needs to the health and depression variance was generally maintained. Length of widowhood was not related either to health or depression, while widows' age was significantly related to both. The findings suggest that needs, as well as resources are necessary concepts for a fuller understanding of the coping process of widows.

Stress research: its present status and issues for future developments

In this article the contribution of nine approaches to stress research is discussed. These approaches are: (1) the biological approach; (2) the (classic) psychosomatic approach; (3) the life event approach; (4) interactionistic or transactional approaches; (5) life style and behavior; (6) group differences; (7) sociocultural (macro-)factors; (8) work and organizational psychology; and (9) intervention and prevention. It is concluded that, more and more, exchanges take place between different approaches and that the willingness to collaborate increases. Not only do we observe collaboration between different disciplines, there also are examples of an integration of laboratory research and field research. In addition, interest of animal workers for human research and vice versa seems to increase. Although it is realized that stress research has its own inherent characteristic problems (e.g. ethics), the authors feel that the future still can bring important progress.

The study of stress and disease: some developments and requirements

This article considers the study of stress in relation to the onset, course, and outcomes of disease, and is divided into three parts. The first part describes the relationships between personality, environmental stressors, and disease. The second focuses specifically on the requirements that must be fulfilled to allow for the conclusion that there is a relationship between stress and the onset of disease. Finally, in the third part models describing the relationship between stress and the course of disease or medical outcome are presented and discussed.