An open trial of meaning-centered grief therapy: Rationale and preliminary evaluation

Adaptation of meaning-centered psychotherapy for healthcare providers to buffer work-induced distress and improve wellbeing

Healthcare providers (HCPs) face high rates of distress, experienced as burnout, moral distress, compassion fatigue, and grief. HCPs are also experiencing a crisis in meaning whereby distress is associated with disconnection from meaning in work and, in turn, a lack of meaning in work can further perpetuate distress for HCPs. Although scalable systems-level solutions are needed to tackle multidimensional HCP distress, it is also necessary to address HCP suffering at individual, team, and institutional levels. Targeted interventions to alleviate HCP distress are limited. Meaning-centered psychotherapy (MCP), a brief, evidence-based, intervention first developed for persons with advanced cancer, holds promise to mitigate HCP distress. This study adapted MCP for HCPs through feedback from a multidisciplinary sample of clinicians trained in MCP and working in healthcare settings. A survey was distributed electronically between November and December 2023 to HCPs previously trained in MCP assessing quantitative and qualitative feedback on the appropriateness of MCP for HCPs, the relevance of MCP session topics and exercises, and implementation barriers and facilitators. Descriptive statistics on relevant participant ratings were calculated; a matrix analysis approach was used for qualitative data. Forty participants, primarily mental health providers, expressed that MCP principles were highly relevant for HCPs and offered key insights on appropriate intervention modifications, including the need for a primary focus on meaning in professional life, reduced intervention length, and delivery in group format. Feedback informed critical adjustments to promote appropriateness and acceptability of MCP-HCP which is poised for pilot testing to determine its feasibility and preliminary efficacy for HCPs.

Ayahuasca-assisted meaning reconstruction therapy for grief: a non-randomized clinical trial protocol

Background

Psychotherapy for Prolonged Grief Disorder (PGD), a condition characterized by an intense and persistent grief response, has received increased attention over the past decades. Evidence-based approaches to prevent PGD are currently scarce, and not always effective. This paper introduces a protocol for a clinical trial exploring the effectiveness of a Meaning Reconstruction psychotherapy approach (MR) assisted with ayahuasca, a traditional indigenous medicine.

Method

The outlined protocol is a three-arm, non-randomized controlled trial focused on reducing normal and pathological grief symptoms, comparing the effectiveness of Ayahuasca-assisted MR therapy (A-MR), MR therapy alone (MR) and No Treatment (NT). At least 69 people who lost a first-degree relative during the prior year, and with a Texas Revised Inventory of Grief score up 39 (TRIG ≥ 40), will participate in the trial. Participants will be allocated to an A-MR (n ≥ 23), MR (n ≥ 23) or NT (n ≥ 23) group. Those from the A-MR and MR therapy groups will undergo a therapeutic process involving 9 sessions of online psychotherapy. In addition, the A-MR condition involves 2 group sessions of ayahuasca. The primary outcomes will be normal and pathological grief severity as measured by the TRIG and Traumatic Grief Inventory Self-Report (TGI-SR), administered at baseline, post-treatment, and 3-month follow up. Measures of quality of life, post-traumatic growth, meaning-made, psychological flexibility, and self-belief consistency will be also included. In addition, subjective effects of ayahuasca and acceptance-avoidance promoting effects will be assessed following ayahuasca administration. Finally, we will analyze the potential mediating effect of meaning-made, psychological flexibility and self-belief consistency in grief symptoms (as measured by the TRIG and TGI).

Discussion

This trial is the first to empirically examinate the potential of psychedelic-assisted psychotherapy for grief, as well as the potential processes of change that may account for it.

Clinical trial registration

https://clinicaltrials.gov, identifier NCT06150859.

The Meaning in Loss protocol: A clinical trial of online grief therapy

For a minority of the bereaved, the loss of a significant other can trigger an overwhelming emotional reaction and impaired functioning across life domains, known as prolonged grief disorder (PGD). Hence, ongoing efforts have been made to refine existing treatments to increase their efficacy and to accommodate the idiosyncrasies of grief reactions. This study presents the results of an open clinical trial of the feasibility and effectiveness of the Meaning in Loss (MIL) protocol in an online format. The brief intervention of 12 to 16 sessions combines constructivist and narrative strategies to explore and work through impediments to meaning reconstruction in loss. The sample included 25 participants diagnosed with PGD who were treated by six therapists. Baseline and post-therapy comparisons showed a significant improvement in all clinical measures (grief symptomatology, depression and general distress) and an increase of meaning making regarding the loss. Meaning making was found to be a prospective mediator of symptomatic improvement in grief across the course of therapy. These findings suggest the effectiveness of the MIL protocol in decreasing grief specific and associated symptomatology and argue for the relevance of further controlled evaluations of its efficacy. Moreover, results confirm previous findings that meaning making is a relevant factor in the evolution of grief reactions, including in the context of psychotherapy.

Digital storytelling: Narrating meaning in bereavement

Individuals who cannot make sense of a significant death are more likely to experience bereavement complications than those who are able to reconcile their loss with existing or newly-developed ways of understanding the world. Digital Storytelling, a multi-media narrative technique, has been identified as a potential facilitator of meaning-making processes. In this secondary qualitative analysis, researchers described the meaning-making processes evident in bereaved individuals' (N = 14) personally-created digital stories, identifying sense making, benefit finding, continuing bonds, shifting identity, and addressing unfinished business. Findings support prior research and enrich emerging understandings of arts-based interventions as tools to facilitate and communicate meaning-making processes.

State of the Science: Psychotherapeutic Interventions for Prolonged Grief Disorder

Prolonged grief disorder (PGD) is a distinct diagnostic entity that has recently garnered considerable attention as it describes an intense, enduring, distressing and disabling bereavement reaction experienced by a small minority of community-based mourners. In recent decades, research has exploded to address how best to treat PGD with different psychotherapeutic interventions. In this state-of-the-science review, the strength of the evidence will be discussed regarding common psychotherapeutic interventions used to treat grief. Specifically, we focus on the most commonly used interventions, cognitive behavioral (CB)-based therapies, bereavement and support groups, and brief contact interventions (BCIs), in an effort to summarize the relevant clinical takeaways of the current available research. A discussion of the use of these therapies in specific clinical populations is also included, with a focus on those traumatically bereaved, pediatric populations, communities of color, and underserved communities. Important foci and directions for future research are also discussed.

Storytelling to support legacy making for bereaved parents of children with cancer

Honoring a child's legacy is an essential aspect of meaning-making for bereaved parents, yet little is known about storytelling as a mechanism. Through narrative analysis of 19 bereaved parent interviews focused on legacy, we examined the role of storytelling in creating and sustaining legacy. Most participants (89%) told stories centered around the child's impact and parent's coping, including the child's character and interpersonal relationships during and after their lifetime as well as how the child's legacy influenced parents' grief experiences. Future research is needed to explore the potential impact of storytelling initiatives to support legacy-making for bereaved caregivers.

Remembering the life and dying days of a deceased close other: Memory recall and associations with loss context

Grievers recall memories from both the life of the deceased and the dying days, but differences in recall across these memory types are not well-characterized. In this study, 100 bereaved German adults described up to ten important memories of a deceased close other (M = 7.86). Memories from the dying days were classified into: final memories, health transition events, last time events, and temporal markers. Among those who provided at least one dying days memory (73%), these memories were reported to be recalled privately and shared socially more often than memories from the deceased's life. Memories from the dying days were rated as less emotionally positive than those from the life, and contextual factors from the loss shaped memory recall frequency and emotional valence. Results underscore the need for appropriate end-of-life care to lay a foundation for adaptive remembering and suggest the relevance of dying days memories in therapeutic settings.

Nursing Interventions in Primary Care for the Management of Maladaptive Grief: A Scoping Review

Grief is a natural and self-limited adaptation process to a new reality that emerges after a significant loss (whether real or perceived), with a broad variety of manifestations that exert an impact on a grieving person's health. The study aim was to synthesize the evidence available about the interventions carried out by Primary Health Care nurses, by means of an individual approach to reduce maladaptive grief or maladaptive grief risk. A scoping review was conducted (November and December 2023) through searches in Medline, Cinahl, Web of Science, ProQuest and Scopus using MeSH terms combined with Booleans. Primary research of any design in adult people undergoing grief situations and receiving professional assistance by nurses in the primary, home and community care contexts published after 2009 in English, Spanish or Portuguese languages were included. Excluded publications were those conducted in in-hospital clinical settings and which did not correspond to research designs or the gray literature. The screening process was carried out by two reviewers using the appropriate JBI critical appraisal tools for each design and discrepancies were resolved by a third reviewer. A total of n = 10 studies were included (n = 4 qualitative, n = 2 RCTs, n = 1 quasi-experimental, n = 2 cross-sectional observational, and n = 2 mixed methods). The qualitative studies identified topics and subtopics of professionals' and families' experiences of grief. The observational studies analyzed symptoms and factors associated with the grieving process. Interventions consisted of cognitive-behavioral therapies delivered by psychological specialists who assessed the severity of grief in a range of cultural contexts using different instruments. The evidence retrieved from the studies that address the reduction in maladaptive grief or maladaptive grief risk is not conclusive. There is a need to increase both the number and the methodological quality of studies assessing the effectiveness of Nursing care in Primary Health Care for individuals experiencing maladaptive grief or maladaptive grief risk. Further research should focus on experimental studies, developing specific interventions conducted by nurses to address individual's grief and prevent maladaptive grief.

EMPOWER: A Multi-Site Pilot Trial to Reduce Distress in Surrogate Decision-Makers in the ICU

CONTEXT

Efforts to reduce the psychological distress of surrogate decision-makers of critically ill patients have had limited success, and some have even exacerbated distress.

OBJECTIVES

The aim of this study was to determine the feasibility, acceptability, and preliminary efficacy of EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), an ultra-brief (∼2-hour), 6-module manualized psychological intervention for surrogates.

METHODS

Surrogates who reported significant anxiety and/or an emotionally close relationship with the patient (n=60) were randomized to receive EMPOWER or enhanced usual care (EUC) at one of three metropolitan hospitals. Participants completed evaluations of EMPOWER's acceptability and measures of psychological distress pre-intervention, immediately post-intervention, and at 1- and 3-month follow-up assessments.

RESULTS

Delivery of EMPOWER appeared feasible, with 89% of participants completing all 6 modules, and acceptable, with high ratings of satisfaction (mean=4.5/5, SD = .90). Compared to EUC, intent-to-treat analyses showed EMPOWER was superior at reducing peritraumatic distress (Cohen's d = -0.21, small effect) immediately post-intervention and grief intensity (d = -0.70, medium-large effect), posttraumatic stress (d = -0.74, medium-large effect), experiential avoidance (d = -0.46, medium effect), and depression (d = -0.34, small effect) 3 months post-intervention. Surrogate satisfaction with overall critical care (d = 0.27, small effect) was higher among surrogates randomized to EMPOWER.

CONCLUSIONS

EMPOWER appeared feasible and acceptable, increased surrogates' satisfaction with critical care, and prevented escalation of posttraumatic stress, grief, and depression 3 months later.

Insights on spirituality and bereavement: A systematic review of qualitative studies

AIM

To describe a synthesis of the experience related to the spirituality of those living a bereavement journey in primary qualitative studies.

DESIGN

A systematic review of qualitative studies.

DATA SOURCE

A systematic review was carried out in March 2019 and was updated in January 2023. Searching was accomplished by an online database, such as CINAHL, MEDLINE, PsycINFO, MedicLatina, LILACS, SciELO and Academic Search Complete. The search strategy did not consider a timeline as an eligibility criterion. The quality of the studies was assessed, and a thematic synthesis was performed in this review.

METHODS

A systematic review of qualitative studies was conducted according to Saini and Shlonsky's methodology.

REPORTING METHOD

PRISMA checklist.

RESULTS

The review included 33 articles. Most of the studies were phenomenological and focused on parents' and family experiences of bereavement. Seven significant categories emerged, which match unmet spiritual needs during the grieving process. Two major categories were identified regarding the role of spirituality in bereavement: Spirituality as a process and spirituality as an outcome.

CONCLUSION

In clinical practice, attention to spirituality and providing spiritual care is critical to guarantee a holistic approach for those experiencing bereavement.

IMPLICATIONS

The findings of our study could foster awareness that healthcare professionals should include the spiritual dimension in their clinical practice to provide holistic care to individuals, enhancing the healing process in bereavement.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a systematic review.

Letter Writing as a Clinical Tool in Grief Psychotherapy

The benefits of expressive writing have been explored since at least the 1980s. The effect of expressive bereavement-related writing has been studied primarily in college students, yielding inconclusive results. Nonetheless, recent effective, integrated psychotherapy protocols, targeting complicated and prolonged grief, include writing assignments, typically in the form of letters. The present paper explores how and why letter writing might be effective and meaningful as a therapeutic tool in the context of grief psychotherapy. It describes how working with letters, addressed to the deceased, might help facilitate self-disclosure, promote exposure to what is avoided, confront unfinished business, encourage continuing bonds, and help achieve a coherent narrative around experiences with the loss. As a therapeutic tool, letter writing has the potential to be helpful to many bereaved people, as it is a simple, effective, and meaningful way to access and work with relevant clinical material in the context of psychotherapy.

Effects of an Integrated Treatment Program on Grief and Distress Among Parentally Bereaved Young Adults

This study examined the effectiveness of an 18-session manualized integrative group psychotherapy intervention for parentally bereaved young adults with grief complications. Participants, 63 young adults aged 20-27 years, completed questionnaires assessing symptoms of prolonged grief, PTSD, depression and anxiety prior to and following treatment. Treatment effectiveness was assessed by comparing outcomes for the intervention group to a waitlist comparison group. Results revealed a statistically significant reduction in symptoms of grief (large effects size), PTSD (medium effect sizes), and depression (medium effect size). The treatment did not result in a significant reduction in anxiety symptoms. The study provided preliminary support for this intervention for parentally bereaved young adults.

A Review of Parental Bereavement Interventions: Implications for Clinical Practice, Research, and Policy

The untimely death of a child is an incredibly traumatic experience for parents and their loved ones. It uproots every aspect of their life, leading the bereaved parents to be far more likely to have poorer physical and mental health outcomes. This traumatic form of bereavement should have comprehensive grief-focused, high-quality interventions available for parents and extended family members. The purpose of this rapid review was to explore and describe the bereavement interventions available for parents and family that have been published within the past 5 years. Records identified 123 full-text articles that were reviewed, and 14 of those were included for data extraction and synthesis, using Cochrane Rapid Reviews Methods Group with the addition of keyword searches. The 14 articles were analyzed by evaluating description of bereaved parents, accessibility of interventions, who delivered interventions, and the type and delivery time of interventions. Four types of interventions were identified, including Web-based, community-based, hospital-based, and psychotherapy interventions. This rapid review has implications for clinical practice, research, and health care policy that can increase the availability of support and quality of interventions for bereaved parents and family members.

The study of psychosocial outcomes of parents bereaved by pediatric illness: a scoping review of methodology and sample composition

OBJECTIVE

Parents of children who died of a medical condition experience a range of psychosocial outcomes. The current scoping review aims to summarize the outcomes assessed, methodology, and sample characteristics of recent psychosocial research conducted with this population.

METHODS

Included studies were limited to peer-reviewed, psychosocial outcomes research published between August 2011 and August 2022, written in English, and including caregiver study participants of children who died of a medical condition. Data sources were scholarly journal articles from 9 electronic databases, including Scopus, Web of Science, Academic Search Primer, ProQuest Research Library, PubMed, Embase, PsycINFO, Psychology & Behavioral Sciences Collection, and Health Source: Nursing/Academic Edition. The Mixed Methods Appraisal Tool-2018 evaluated methodological quality.

RESULTS

The study sample included 106 studies, most of which were either qualitative (60%) or quantitative (29%). Mixed-methods studies (8%) and randomized clinical trials (2%) were also identified. Study quality was variable, but most studies met all quality criteria (73%). Studies primarily represented cancer populations (58%), White participants (71%), and mothers (66%). Risk-based psychosocial outcomes (e.g., grief) were more commonly assessed than resilience-based outcomes.

CONCLUSIONS

The current scoping review revealed that recent research assessing the psychosocial outcomes of bereaved parents is limited in the representation of diverse populations, primarily qualitative, of broadly strong methodological quality, and oriented to psychosocial risk. To enhance the state of the science and inform evidence-based psychosocial services, future research should consider varied methodologies to comprehensively assess processes of risk and resilience with demographically and medically diverse populations.

On the concept, taxonomy, and transculturality of disordered grief

The enduring question of whether grief can ever be pathological (and, if so, when) has been shrouding mental health and psychiatric care over the last few years. While this discussion extends beyond the confines of psychiatry to encompass contributions from diverse disciplines such as Anthropology, Sociology, and Philosophy, scrutiny has been mainly directed toward psychiatry for its purported inclination to pathologize grief-an unavoidable facet of the human experience. This critique has gained particular salience considering the formal inclusion of prolonged grief disorder (PGD) in the 11th edition of the International Classification of Diseases (ICD-11) and the subsequent Text Revision 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This study contends that the inclusion of prolonged grief disorder as a diagnostic entity may be excessively rooted in Western cultural perspectives and empirical data, neglecting the nuanced variations in the expression and interpretation of grief across different cultural contexts. The formalization of this disorder not only raises questions about its universality and validity but also poses challenges to transcultural psychiatry, due to poor representation in empirical research and increased risk of misdiagnosis. Additionally, it exacerbates the ongoing concerns related to normativism and the lack of genuine cultural relativism within the DSM. Furthermore, the passionate discussion surrounding the existence, or not, of disordered forms of grief may actually impede effective care for individuals genuinely grappling with pathological forms of grief. In light of these considerations, this study proposes that prolonged grief disorder should be approached as a diagnostic category with potential Western cultural bias until comprehensive cross-cultural studies, conducted in diverse settings, can either substantiate or refute its broader applicability. This recalibration is imperative for advancing a more inclusive and culturally sensitive understanding of grief within the field of psychiatry.

Rewriting the Story of Mid- and Late-Life Family Caregiving: Applying a Narrative Identity Framework

Family caregivers of older people with health needs often provide long-term, intensive support. Caregivers are, in turn, shaped by these caregiving experiences. According to the narrative identity framework, self-narratives from lived experiences influence self-beliefs and behaviors. We assert that family caregiving experiences, filtered through individuals' memory systems as self-narratives, provide substantial scaffolding for navigating novel challenges in late life. Self-narratives from caregiving can guide positive self-beliefs and behaviors, leading to constructive health-focused outcomes, but they also have the potential to guide negative self-beliefs or behaviors, causing adverse consequences for navigating late-life health. We advocate for incorporating the narrative identity framework into existing caregiving stress models and for new programs of research that examine central mechanisms by which caregiving self-narratives guide self-beliefs and behavioral outcomes. To provide a foundation for this research, we outline 3 domains in which caregiving self-narratives may substantially influence health-related outcomes. This article concludes with recommendations for supporting family caregivers moving forward, highlighting narrative therapy interventions as innovative options for reducing the negative consequences of maladaptive caregiving self-narratives.

Role of Post-Traumatic Growth in Bereavement Outcomes: An Inquiry of Family Caregivers in Hospice

Background: Family caregivers (FCGs) encounter several physical, psychosocial, and financial struggles while caring for a dying loved one. After their loved one has passed, FCGs face new difficulties as they transition out of the caregiving role and into bereavement. Recent research has focused on the positive adaptive outcomes of bereavement. Objective: This study examined the relationship between core bereavement experiences and post-traumatic growth (PTG) for bereaved hospice FCGs. Design: This is a quantitative cross-sectional mail-in survey. Settings/Subjects: A total of 395 bereaved FCGs of patients who died while under the care of a comprehensive hospice program were surveyed. Measurements: Demographics were collected. Bereavement experiences were assessed using the core bereavement items, and PTG was assessed using the Posttraumatic Growth Inventory (PTGI). Both surveys are validated measures. Results: Two-tailed bivariate correlations were used to analyze the relationships between bereavement experiences and PTG. Significant positive relationships were found between all bereavement experiences and PTG variables (p = <0.01-0.011, r = 0.134-0.290), except for one variable pairing (grief × new possibilities). Participants who reported more intense bereavement experiences also reported greater PTG, especially in the areas relating to others and appreciation of life. Conclusion: FCGs who undergo more intense bereavement experiences tend to experience greater PTG. This information can be used in the future to develop a more comprehensive understanding of the multifaceted nature of grief and loss.

Existential distress in family caregivers: scoping review of meaning-making interventions

OBJECTIVES

Family and friend caregivers often feel overwhelmed by and ill-prepared for their responsibilities. Many feel helpless living with uncertainty about the outcome of the patient's illness, which leads to existential distress. Supportive care interventions that address existential distress by promoting meaning and purpose buffer the negative effects of caregiver burden and promote resilience and growth. The purpose of this scoping review is to describe the depth and breadth of available interventions targeting caregiver existential distress.

METHODS

We followed the Joanna Briggs Institute's scoping review methods and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension checklist. SCOPUS, Ovid MEDLINE and PsycINFO databases were searched for interventions that targeted existential distress by promoting meaning-making, spiritual well-being, post-traumatic growth and/or benefit finding for caregivers of seriously ill adult patients.

RESULTS

We screened 1377 titles/abstracts and 42 full-text articles. Thirty-one articles (28 unique studies) met inclusion criteria. Most interventions were designed for caregivers supporting patients with cancer (n=14) or patients receiving palliative care (n=9). Promising interventions included Meaning-Centered Psychotherapy for Cancer Caregivers, Meaning-Based Intervention for Patients and their Partners, Legacy Intervention for Family Enactment, Family Participatory Dignity Therapy and Existential Behavioural Therapy. More than half of the studies (n=20, 64%) were in the feasibility/acceptability/pilot stage of intervention testing.

CONCLUSION

Large randomised controlled trials with more diverse samples of caregivers are needed. Future research should explore the impact of delivering meaning-making interventions to caregivers throughout the illness trajectory. Developing strategies for scaling up and conducting cost analyses will narrow the research and practice gap for meaning-making interventions.

Exploring the experience of meaning-centered group psychotherapy among Chinese cancer patients during active treatment: a descriptive qualitative study

Objective

Meaninglessness poses a significant psychological challenge for cancer patients, negatively affecting their quality of life and increasing the risk of suicide. Meaning-Centered Group Therapy (MCGP) is an intervention designed specifically to enhance the meaning of life of cancer patients. Extensive research has documented its effectiveness across various cultures and populations. However, limited research has been conducted on the subjective experiences and perspectives of participants engaged in MCGP. Thus, the purpose of this study was to employ a qualitative design to explore the experiences and viewpoints of Chinese cancer patients who have undergone MCGP.

Methods

Within a two-week timeframe following the conclusion of MCGP, semi-structured interviews were administered to twenty-one participants who had engaged in the therapy. The interview data were transcribed and subjected to thematic analysis.

Results

Four main themes were identified: (a) Self-perceived personal change, (b) Overall experience of group therapy, (c) Barriers to participation of MCGP, and (d) Suggestions for future interventions.

Conclusion

Despite the barriers to participation in the MCGP process, the overall experience for Chinese cancer patients undergoing active treatment is valuable and positive, providing multiple benefits. Future studies could explore the adaptation of MCGP to a broader range of cancer populations and diverse study populations.

The Up-Side of the COVID-19 Pandemic: Are Core Belief Violation and Meaning Making Associated with Post-Traumatic Growth?

The negative impact of the COVID-19 pandemic on mental health has been extensively documented, while its possible positive impact on the individual, defined as Post-Traumatic Growth (PTG), has been much less investigated. The present study examines the association between PTG and socio-demographic aspects, pre-pandemic psychological adjustment, stressors directly linked to COVID-19 and four psychological factors theoretically implicated in the change processes (core belief violation, meaning-making, vulnerability and mortality perception). During the second wave of the pandemic 680 medical patients completed an online survey on direct and indirect COVID-19 stressors, health and demographic information, post-traumatic growth, core belief violation, meaning-making capacity, feelings of vulnerability and perceptions of personal mortality. Violation of core beliefs, feelings of vulnerability and mortality, and pre-pandemic mental illness positively correlated with post-traumatic growth. Moreover, the diagnosis of COVID-19, stronger violation of core beliefs, greater meaning-making ability, and lower pre-existing mental illness predicted greater PTG. Finally, a moderating effect of meaning-making ability was found. The clinical implications were discussed.

Competitive Neurocognitive Processes Following Bereavement

Bereavement is a common human experience that often involves significant impacts on psychological, emotional and even cognitive functioning. Though various psychological theories have been proposed to conceptualize the grief process, our current understanding of the underlying neurocognitive mechanisms of grief is limited. The present paper proposes a neurocognitive model to understand phenomena in typical grief, which links loss-related reactions to underlying learning and executive processes. We posit that the competitive relationship between the basal ganglia (BG) and circuitry involving the medial temporal lobe (MTL) underlies common cognitive experiences in grief such as a sense of "brain fog." Due to the intense stressor of bereavement, we suggest that these two systems' usually flexible interactive relationship become imbalanced. The resulting temporary dominance of either the BG or the MTL system is then manifested in perceived cognitive changes. Understanding the underlying neurocognitive mechanism in grief could inform ways to best support bereaved individuals.

Experience of application of the meaning-centered psychotherapy to Japanese bereaved family of patients with cancer – A mixed-method study

Objectives

This study aimed to adapt the meaning-centered psychotherapy (MCP) to treat post-bereavement grief in Japanese bereaved families who lost their loved ones to cancer and to examine the feasibility of the intervention using both quantitative and qualitative methods.

Methods

A modified version of MCP was developed with cultural consideration. Bereaved individuals aged ≥18 years who had lost their family members to cancer at least 6 months before and had severe or persistent grief with a score of ≥26 on the Inventory of Complicated Grief (ICG-19) were included in the study. The participants received the modified version of MCP, which was provided in a 5-session monthly format. The levels of grief (ICG-19), depression (Center for Epidemiologic Studies Depression Scale [CES-D]), general health (General Health Questionnaire-12), and post-traumatic growth (Post-traumatic Growth Inventory -Short Form) were compared before and after the intervention.

Results

Five bereaved individuals were enrolled, and all the participants completed the program. The mean scores of the ICG-19. The participants’ sense of regret, guilt, and being separated from the deceased person gradually shifted to the reappraisal of the experience, leading to a broadened view of the relationship with the deceased, and rediscovery of the core values, identity, and roles of the participants through the process of rediscovery of the meaning of life.

Significance of results

A modified version of the MCP was well accepted by Japanese bereaved families. The intervention appears to promote the rediscovery of the meaning of life and appears to have the potential to alleviate the bereaved individuals’ depression and grief-related symptoms and to facilitate their post-traumatic growth.

The loss of a child, bereavement and the search for meaning: A systematic review of the most recent parental interventions

The loss of a child is considered one of the most tragic experiences that parents can go through. The present systematic review aims to compile the most recently published interventions in bereavement support for these parents, being particularly interested in those made from a meaning-centered approach. The search for the units of analysis was guided by the standards of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement and was entered in Web of Science, Scopus and EBSCO, obtaining a total of 485 papers of which 21 have been included in this article. The results found are heterogeneous in terms of the type of intervention used and results, but they all seem to have something in common: the lack of research and reliable interventions that exist for this population. With this systematic review we intend to achieve a better understanding of these parents' needs and to highlight the enormous work that still remains ahead in order to make their bereavement experience a little less devastating.

The Critical Need for a Meaning-Centered Team-Level Intervention to Address Healthcare Provider Distress Now

COVID-19 has unveiled and amplified the burnout, grief, and other forms of distress among healthcare providers (HCPs) that long preceded the pandemic. The suffering of the healthcare workforce cannot be simply and sufficiently addressed with a single psychotherapeutic intervention. Nevertheless, the National Academies of Sciences, Engineering, and Medicine Studies recommended prioritizing interventions that generate an increased sense of meaning in life and in work to reduce burnout and cultivate clinician wellbeing. Despite their guidance, there is a dearth of interventions for HCPs specifically targeting meaning and purpose as an avenue to reduce HCP distress. In a time when such an intervention has never been more essential, Meaning-Centered Pyschotherapy (MCP), a brief, evidence-based intervention designed for patients with advanced cancer may be key. This piece describes the principles underlying MCP and how it might be adapted and applied to ameliorate burnout among HCPs while providing a rationale to support future empirical studies in this area. Importantly, the systemic factors that contribute to the emotional and mental health burdens of HCPs are discussed, emphasizing the need for systems-level changes that are needed to leverage the potential outcomes of MCP for HCPs.

Bereaved Families: A Qualitative Study of Therapeutic Intervention

Background

A child's death is the most stressful event and the most complex grief that families face. The process of psychological adaptation to the illness and death of a child is difficult due to a variety of emotional reactions. Parental grief had received the attention of researchers only in recent years when it became clear that this reality differs substantially from the general grief process.

Objective

This work aims to highlight the needs of bereaved parents; increase the specificity and effectiveness of the therapeutic approach to prevent complications in the process of loss-making; and find the recurrent thematic nuclei in the development of bereavement present in a therapeutic group of parents who have lost their child to an onco-hematological disease.

Method

Between 2011 and 2016, five therapeutic groups for the grief elaboration were made. The sample included a total of 50 parents of children who died from cancer between the ages of 0 and 21 years.Content analysis was carried out as a qualitative analysis method. The SAS^® Text Miner software (SAS Institute Inc, 2004) was used to read, interpret, classify and integrate the data from numerous sources.

Results

The development and consecutive interpretation of the 5 clusters have been carried out to analyze the related topics using the node "Topic Analysis" and requesting the subdivision into five topics. Four topics have been well defined. Clear topics are reducible to categories of emotional relief, tools, legacy, and unfinished business. The topic analysis provides interesting indications about the different interpretive journeys of the bereavement situation and offers ideas regarding the different types of social responses.

Conclusions

After reviewing the existing bibliography, we have confirmed the lack of specific literature on the problem of grief in parents whose children have died from cancer. Much research has shown that parents who lose a child to cancer want support, and there are still few studies on the most effective interventions for this group.

Meaning Co-Construction: Facilitating Shared Family Meaning-Making in Bereavement

Meaning-oriented approaches to grief therapy have made substantial contributions by defining the internal processes of meaning-making and, more recently, clinical scholars have introduced relational approaches as means for continuing bonds with the deceased and increasing social support for the bereaved. However, the complicated interactive processes of interpersonal meaning-making pose added challenges as family members attempt to coregulate each other's grief experiences. While systemic therapists have consistently emphasized the essential role of familial relationships in fostering resilience through interpersonally constructed meaning, there remains a need for clarity in terms of the specific processes by which this occurs. The Meaning Reconstruction Model and Emotionally Focused Therapy provide process-oriented therapeutic strategies for facilitating interpersonal interactions that foster deep relational connection and self-identity transformation. In this article, we explore how these models can be integrated and applied to the dynamic needs of families who are adjusting to loss. Future clinical and research directions are also discussed.

Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial

BACKGROUND

Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce.

OBJECTIVE

The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement.

METHODS

The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures.

RESULTS

A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; η²=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health.

CONCLUSIONS

The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer.

TRIAL REGISTRATION

German Clinical Trial Register U1111-1186-6255; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001.

A micro-sociological theory of adjustment to loss

Although grief is a reaction to a social loss, it has been viewed almost exclusively through the lens of individual psychology and not sociology. In this article, we suggest that more attention to sociological aspects of grief is warranted. We propose a micro-sociological theory of bereavement and grief to complement, not replace, psychological perspectives. We assert that bereavement represents a state of loss-associated social deprivations (e.g. social disconnection). Furthermore, we postulate that addressing social deprivations (e.g. enhancing social connection) will lessen severity of distressing, disabling grief and, thereby, promote adjustment to loss. Future research is needed to test our theory and the hypotheses that follow from it in the service of promoting adaptation to bereavement.

Experiences of Norwegian Mothers Attending an Online Course of Therapeutic Writing Following the Unexpected Death of a Child

The unexpected death of a child is one of the most challenging losses as it fractures survivors' sense of parenthood and other layers of identity. Given that not all the bereaved parents who have need for support respond well to available treatments and that many have little access to further intervention or follow-up over time, online interventions featuring therapeutic writing and peer support have strong potential. In this article we explore how a group of bereaved mothers experienced the process of participating in an online course in therapeutic writing for the integration of grief. Our research questions were: How do parents who have lost a child experience being part of an online course in therapeutic writing? What are the perceived benefits and challenges of writing in processing their grief? We followed an existential phenomenological approach and analyzed fieldwork notes (n = 13), qualitative data from the application and assessment surveys (n = 35; n = 21), excerpts from the journals of some participants (n = 3), and email correspondence with some participants (n = 5). We categorized the results in three meaning units: (1) where does my story begin? The "both and" of their silent chaos; (2) standing on the middle line: a pregnancy that does not end; (3) closures and openings: "careful optimism" and the need for community support. Participants experienced writing as an opportunity for self-exploration regarding their identities and their emotional world, as well as a means to develop and strengthen a bond with their children. They also experienced a sense of belonging, validation, and acceptance in the online group in a way that helped them make sense of their suffering. Online writing courses could be of benefit for bereaved parents who are grieving the unexpected death of a child, but do not replace other interventions such as psychotherapy. In addition to trauma and attachment informed models of grief, identity informed models with a developmental focus might enhance the impact of both low-threshold community interventions and more intensive clinical ones. Further studies and theoretical development in the area are needed, addressing dialogical notions such as the multivoicedness of the self.

Spanish Adaptation of Meaning-Centered Psychotherapy for Participants With Cancer: Study Protocol of a Randomized Control Trial

BACKGROUND

Meaning-Centered Psychotherapy (MCP) is effective in improving meaning in life, hope, optimism, self-efficacy, well-being, and quality of life, and in reducing stress in people with cancer. However, all the studies on the application of MCP in cancer patients have been carried out in Anglo-Saxon samples. Therefore, it is necessary to adapt and verify the efficacy of MCP in populations that speak languages other than English, such as Spanish. Moreover, to expand the data supporting the efficacy of MCP for cancer patients, it would be necessary to compare MCP to other active therapies such as Cognitive Behavioral Therapy (CBT).

METHODS

The aims of the proposed study are: the first objective is to verify the efficacy of the MCP intervention for Spanish participants with cancer in a randomized control trial (RCT) comparing it to CBT. The second objective is to analyze the feasibility and acceptance of MCP in Spanish participants with cancer. The third objective is to analyze whether the changes produced in the meaning in life dimensions (presence, search, comprehension, purpose, and mattering) will predict changes in anxiety, depression, quality of life, etc. Our research team adapted MCP for Spanish participants with cancer. This paper presents the study protocol. The study design consists of a two-arm RCT with two conditions: MCP and CBT, where participants will be randomized to one of the two groups. Eligible participants will be adults with stage I, II, and III cancer who were treated with curative intent and had completed their main medical treatment (surgery, radiotherapy, or chemotherapy). Participants will be assessed at pretreatment, post-treatment, and 6-month follow-up. The intention-to-treat principle will be used when analyzing data, using mixed-effects models with full information and maximum likelihood estimation.

DISCUSSION

This study will provide results that confirm the efficacy of the MCP in Spanish participants with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov; https://register.clinicaltrials.gov/prs/app/template/Home.vm?uid=U0005WS9&ts=4&sid=S000BOTT&cx=bvr2ue, identifier NCT05197348.

Review of Grief Therapies for Older Adults

Purpose of Review

The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic.

Findings

The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic.

Summary

Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Perception of grief responses: Are maladaptive grief responses and the stages of grief considered normal?

Literature indicates laypeople hold strong opinions about how persons should grieve. This study examined how individuals perceive normal grief. Participants across two distinct samples (Study 1: N = 510 via MTurk; Study 2: N = 210 via Qualtrics panels) completed the Perception of Grief Scale and Grief Expectations Questionnaire. Findings indicated participants endorsed maladaptive grief responses as normal relative to other responses to loss. Endorsement of maladaptive grief responses as normal predicted endorsement of grief work beliefs. If social expectations deem maladaptive grief to be normal, as this study suggests, bereaved individuals might implicitly push themselves to grieve maladaptively.

Risk factors for dysfunctional grief and functional impairment for all causes of death during the COVID-19 pandemic: The mediating role of meaning

The COVID-19 pandemic, coupled with significant social changes due to legislative and public health requirements, has changed the way in which people experience grief. We examined whether dysfunctional grief symptoms, disrupted meaning, risk factors, and functional impairment differed between people bereaved from COVID-19 and from other natural or violent causes in this same period. A sample of 409 participants (67.73% male; M = 37.54 years) completed an online survey in June 2021. There were no statistically significant differences between the three groups on any of the outcome variables; all three groups manifested clinical levels of functional impairment equal to or greater than bereaved groups diagnosed with complicated or prolonged grief disorder prior to the pandemic. Disrupted meaning partially mediated the relationship between risk factors on the one hand and functional impairment and dysfunctional grief symptoms on the other. Findings indicate that deaths during COVID-19, rather than deaths from COVID-19, may precipitate symptoms of significant clinical concern.

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

OBJECTIVE

The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes.

METHOD

Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.

RESULTS

Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30).

SIGNIFICANCE OF RESULTS

Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Process of therapeutic changes in Meaning-Centered Group Psychotherapy adapted to the Portuguese language: A narrative analysis

OBJECTIVE

The aim was to understand the processes of therapeutic changes in Meaning-Centered Group Psychotherapy (MCGP) in a Portuguese sample.

METHOD

Adult cancer patients with distress motivated to participate in MCGP were identified; descriptive and narrative analyses were performed on the session content.

RESULTS

The sample had 24 participants (mean age: 63.43 years); the majority were females (75%), with a median academic degree (54%). Breast cancer was most frequent (67%) at the localized stage (71%). The narrative analysis defined seven categories according to the MCGP themes. In "Moments with Meaning (MwM)," the most relevant dimensions were related to interpersonal relations, the moment of diagnosis, and personal achievements. This category established relations with almost all other categories, as did the category "historical sources of meaning (SoM)." The category "identity before and after cancer diagnosis" was only related to "attitudinal SoM" and "transitions." Historical SoM had two dimensions, "past" and "present and future" legacies, in which prominent topics related to family, childhood, achieved goals, and values to pass to others explored. Attitudinal SoM established relations only with the category "creative SoM," in which "courage" and "responsibility" were the main dimensions, which were also related to "MwM," "historical," and "attitudinal SoM." Experiential SoM, with the main dimension "love," was related to "MwM" and "historical SoM." Transitions only established relations with "historical SoM" and "identity before and after cancer."

SIGNIFICANCE OF RESULTS

The findings that "MwM" and "historical SoM" were the categories which established a solid pattern of relations suggest that these are the main psychotherapy topics that can have more influence for the participants; one explanation is that these categories imply a concrete way of thinking, which is easier to understand. This process of therapeutic changes must be integrated in a cultural context, as it is well known to have an impact upon the "meaning" of life.

Crosstalk between Existential Phenomenological Psychotherapy and Neurological Sciences in Mood and Anxiety Disorders

Psychotherapy is a comprehensive biological treatment modifying complex underlying cognitive, emotional, behavioral, and regulatory responses in the brain, leading patients with mental illness to a new interpretation of the sense of self and others. Psychotherapy is an art of science integrated with psychology and/or philosophy. Neurological sciences study the neurological basis of cognition, memory, and behavior as well as the impact of neurological damage and disease on these functions, and their treatment. Both psychotherapy and neurological sciences deal with the brain; nevertheless, they continue to stay polarized. Existential phenomenological psychotherapy (EPP) has been in the forefront of meaning-centered counseling for almost a century. The phenomenological approach in psychotherapy originated in the works of Martin Heidegger, Ludwig Binswanger, Medard Boss, and Viktor Frankl, and it has been committed to accounting for the existential possibilities and limitations of one's life. EPP provides philosophically rich interpretations and empowers counseling techniques to assist mentally suffering individuals by finding meaning and purpose to life. The approach has proven to be effective in treating mood and anxiety disorders. This narrative review article demonstrates the development of EPP, the therapeutic methodology, evidence-based accounts of its curative techniques, current understanding of mood and anxiety disorders in neurological sciences, and a possible converging path to translate and integrate meaning-centered psychotherapy and neuroscience, concluding that the EPP may potentially play a synergistic role with the currently prevailing medication-based approaches for the treatment of mood and anxiety disorders.

A quest for meaning: A qualitative exploration among children with advanced cancer and their parents

OBJECTIVE

Meaning-making may assist individuals in adaptation to stressful life events, particularly bereavement. However, few studies have examined meaning-making among pediatric populations with advanced illness to understand how this process unfolds before the child's death. This study explores meaning-making pre-bereavement among children with advanced cancer and their parents.

METHODS

As part of a larger study examining shared decision-making near the end of life, 24 children with advanced cancer and/or high-risk cancer, 26 mothers, and 11 fathers participated in individual, semi-structured interviews. Analyses focused on questions regarding meaning-making. Four coders analyzed the data via directed content analysis.

RESULTS

Three major meaning-making themes emerged: (1) sense-making (i.e., unknown, no sense/meaning, religious/spiritual explanations, scientific explanations), (2) benefit-finding, and (3) purpose/legacy. Some stated they were unable to make sense of the diagnosis, because there was no reason, they were not there yet, or they were dealing with the situation and moving forward. Others reported finding meaning through spiritual and scientific explanations. Many identified benefits related to the child's illness, such as personal growth and stronger relationships. Some parents expressed their purpose in life was to live for their children, while others shared their child's legacy as a way to find meaning.

CONCLUSIONS

Our findings highlight the struggle children and parents often face when attempting to make sense of the child's advanced or high-risk illness. Clinicians might consider if meaning-centered interventions designed for use in adults at the end of life and bereaved parents may be helpful for children with advanced or high-risk cancer and their parents.

Parents' views on what facilitated or complicated their grief after losing a child to cancer

OBJECTIVES

The loss of a child is a devastating event, and bereaved parents often suffer intense and long-lasting grief reactions and are at risk for psychological symptoms. More knowledge about how parents cope with grief may improve the support to bereaved parents. This study, therefore, aimed to explore parents' views on what facilitated or complicated their grief coping after losing a child to cancer.

METHODS

This study was derived from a nationwide postal survey. Cancer-bereaved parents (n = 161) provided written responses to two open-ended questions: "Is there anything that has helped you cope with your grief after your child's death?" and "Is there anything that made it difficult for you to cope with your grief?" Content analysis was used to analyze the responses.

RESULTS

Parents reported that a supportive social network of family and friends, and having remaining children, facilitated their coping with grief. Meeting professional counselors and meeting other bereaved parents, connecting to memories of the deceased child in various contexts, including school and pediatric care settings, were also reported facilitating grief coping. Parents stated that the following experiences had complicated grief coping: additional losses in their family or social network; not being able to share emotions with their partner; when they perceived that friends, relatives, or colleagues lacked empathy or patience; when they felt challenging demands from employers at a too early stage.

SIGNIFICANCE OF RESULTS

This study contributes to the understanding of parents' grief experiences and what has facilitated or complicated their coping with grief, which can help health care professionals and others improve bereavement support services.

Bereavement risk screening: A pathway to psychosocial oncology care

OBJECTIVE

This qualitative study sought to obtain feedback from stakeholder cancer caregivers and bereaved family members on the implementation of bereavement risk screening in oncology.

METHODS

Semi-structured interviews were conducted with 38 family members of patients with advanced cancer (n = 12) and bereaved family members (n = 26) on when and how to effectively implement bereavement risk screening. Data were analyzed using thematic analysis.

RESULTS

Many participants indicated that they would be open to completing a self-report screening measure before and after the patient's death. Several suggested screening at multiple timepoints and the importance of follow-up. Participants viewed screening as an opportunity to connect to psychosocial support.

CONCLUSIONS

The findings suggest that family members appear supportive of sensitively approached bereavement risk screening before and after a patient's death as an important component of quality psychosocial care. To optimize implementation, bereavement risk screening would involve screening at multiple timepoints and include follow-up. Findings suggest standardized risk screening using a brief, validated self-report tool would be a pragmatic approach to increasing access to bereavement care.

A Systematic Review of Treatment Options for Grieving Older Adults

Purpose of review

a)The purpose of this systematic review was to characterize the studies published on grief interventions for bereaved older adults in the last 5 years. Grief intervention studies were included that exclusively focused on older adults as well as those that included older adults in their samples, in order to summarize the most up-to-date treatment options available for bereaved older adults.

Recent findings

b)Twenty-four articles that investigated grief interventions in older adults were identified. Generally, findings suggest viable treatment approaches for bereaved older adults are those incorporating behavioral activation and guidance on restoration-oriented coping. However, similar to studies of broader adult populations, grief interventions had small effects on grief-related symptoms in older adults. Few studies examined age as a moderator of treatment effects. Studies varied greatly by study design, sample size, and outcomes measured, which all likely impacted the efficacy of results.

Summary

c)This review suggests that, while there has been a growing focus on older adults, who have unique vulnerabilities in bereavement, the evidence-base of efficacious interventions for this population is limited. Given the need for specialized bereavement support for older adults will increase in the coming years, future research should prioritize rigorous investigations of grief treatment options leveraging technology to increase access and incorporate techniques that enhance engagement in life and connectedness for this vulnerable population.

Waiting and "weighted down": the challenge of anticipatory loss for individuals and families with Li-Fraumeni Syndrome

Li-Fraumeni Syndrome (LFS) is characterized by risk of multiple primary malignancies in diverse sites, pediatric onset, near complete penetrance by age 70 years, limited options for prevention, and substantial uncertainty regarding disease manifestation and prognosis. Forty-five families, including 117 individuals aged 13-81 years, enrolled in the US National Cancer Institute's Li-Fraumeni Syndrome Study completed 66 interviews regarding their LFS experiences. An interdisciplinary team used modified grounded theory to examine family distress regarding expectations of loss and change due to likely cancer diagnoses, and the consequences of this likelihood across physical, social, and emotional domains. Disease-free periods were characterized by fearful anticipation of diagnosis or recurrence, uncertainty regarding post-treatment quality of life, and planning for shifts in family dynamics to enable caregiving. The chronicity of waiting for these changes incited dread and inhibited effective coping with the pragmatic, emotional, and existential challenges of the syndrome. Consequently, families reported high burden on roles and resources and limited guidance to prepare for, or achieve resolution with, grief. Anticipatory loss, the experience of bereavement prior to an expected change, distinguishes hereditary cancer risk from a sporadic diagnosis. Such grief is often incomplete in impact or meaning, subjected to rapid or profound change as conditions worsen, and poorly understood. In this study, losses were compounded by profound uncertainty, a chronic feature of LFS, which compromised mourning. Long-term engagement of mental health providers with bereavement training, in partnership with genetics providers, can provide invaluable educational and psychological support to families as they navigate these implacable challenges.

Prolonged Grief, Posttraumatic Stress, and Depression Among Bereaved Parents: Prevalence and Response to an Intervention Program

Bereaved parents may experience diverse psychological symptoms. Possible interventions are not yet well established. In this study, the psychological symptoms of 323 bereaved parents (mean age = 39.97, SD = 7.21, 52.0% female), referred to a 4-week family-oriented rehabilitation (FOR) program, were assessed. The baseline assessments indicated that 160 (49.5%) parents showed symptoms of prolonged grief disorder (PGD). Complicated grief was indicated in 272 (84.2%), depression in 191 (59.1%), and posttraumatic stress disorder in 242 (74.9%) parents. Mothers were at higher risk of complicated grief ( p ≤ .001), depression ( p = .029), and posttraumatic stress disorder ( p = .004), compared to fathers. Significant remissions of symptoms between admission and discharge from the program are presented as symptoms of complicated grief, depression, and posttraumatic stress. The effect sizes ranged between d = 0.68 and 1.22. In addition, significantly fewer parents fulfilled PGD criteria on discharge from the FOR program ( p ≤ .001). The special FOR program appears promising with regard to improving the bereaved parents’ mental health.

Regret and unfinished business in parents bereaved by cancer: A mixed methods study

BACKGROUND

Prior research has demonstrated that the presence of regret and unfinished business is associated with poorer adjustment in bereavement. Though there is a growing literature on these constructs among caregivers of adult patients, the literature on regret and unfinished business in bereaved parents has been limited.

AIM

The aim of this study was to examine regret and unfinished business in parents bereaved by cancer, as well as their associations with caregiving experiences and prolonged grief.

DESIGN

This was a cross-sectional mixed methods study that utilized self-report questionnaires with open-ended items.

SETTING/PARTICIPANTS

The multisite study took place at a tertiary cancer hospital and pediatric cancer clinical research institution. Participants were 118 parents (mothers = 82, fathers = 36) who lost a child aged 6 months to 25 years to cancer between 6 months and 6 years prior.

RESULTS

Results showed that 73% of the parents endorsed regret and 33% endorsed unfinished business, both of which were more common among mothers than fathers (p ⩽ 0.05). Parents were on average moderately distressed by their regrets and unfinished business, and both regret-related and unfinished business-related distress were associated with distress while caregiving and prolonged grief symptoms.

CONCLUSION

Findings have implications for how providers work with families, including increasing treatment decision-making support, supporting parents in speaking to their child about illness, and, in bereavement, validating choices made. Grief interventions that use cognitive-behavioral and meaning-centered approaches may be particularly beneficial.

Advances in pediatric psychooncology

PURPOSE OF REVIEW

This article reviews the current literature on psychosocial care of children with cancer with particular focus on evidence-based standards of care, including developments in systematic distress screening, utilization of patient-reported outcomes, evidence-based interventions, survivorship, palliative care and bereavement.

RECENT FINDINGS

Although attention to the psychosocial needs of the child and family is increasingly recognized as an essential element of care for children with cancer, implementing evidence-based care remains suboptimal. Recent efforts have focused on utilizing technology to improve the reach of these interventions and to enhance engagement with special populations, such as adolescents and young adults. Increasing data elucidate the long-term psychological and physical late effects of childhood cancer survivorship and the impact of cancer on siblings and the family. Gaps in clinical care and important directions for future research include the needs of infants and toddlers, overlooked minorities, and patients with hereditary tumor predisposition syndromes, and attention to the psychosocial impact of exciting new treatments, such as autologous chimeric antigen receptor (CAR) T-cell therapy.

SUMMARY

The evidence base for the psychosocial standards of care for children with cancer and their families continues to grow, but more work is needed to successfully implement these standards across pediatric cancer centers.

Psychotherapy at the End of Life

Dr. Elisabeth Kübler-Ross is credited as one of the first clinicians to formalize recommendations for working with patients with advanced medical illnesses. In her seminal book, On Death and Dying, she identified a glaring gap in our understanding of how people cope with death, both on the part of the terminally ill patients that face death and as the clinicians who care for these patients. Now, 50 years later, a substantial and ever-growing body of research has identified "best practices" for end of life care and provides confirmation and support for many of the therapeutic practices originally recommended by Dr. Kübler-Ross. This paper reviews the empirical study of psychological well-being and distress at the end of life. Specifically, we review what has been learned from studies of patient desire for hastened death and the early debates around physician assisted suicide, as well as demonstrating how these studies, informed by existential principles, have led to the development of manualized psychotherapies for patients with advanced disease. The ultimate goal of these interventions has been to attenuate suffering and help terminally ill patients and their families maintain a sense of dignity, meaning, and peace as they approach the end of life. Two well-established, empirically supported psychotherapies for patients at the end of life, Dignity Therapy and Meaning Centered Psychotherapy are reviewed in detail.