Applying an empty-chair monologue paradigm to examine unresolved grief

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.

Grief and mourning in Covid-19 pandemic and delayed business as a new concept

The measures, restrictions, and death-related rituals in the COVID-19 pandemic have affected the mourning-related routines of individuals. Moreover, mourning processes have been affected by the restriction of death-related cultural rituals, funeral ceremonies performed only by the officials, and the prohibition of visiting graves. This study aims to investigate the experiences of individuals who lost their loved ones in Turkey during the COVID-19 pandemic. For that purpose, the phenomenological method is employed in the design of the study. Individual interviews were conducted with nine participants who lost their relatives during the COVID-19 pandemic. Data were collected through semi-structured interview forms prepared by the researchers. The study participants described the various factors contributing to the grief and mourning process in the COVID-19 pandemic. These factors were categorized into three following main categories: grief and mourning responses of the individuals lost loved ones, including cognitive, emotional, and behavioral responses; risk factors including the expectation of harm, unfinished business, and restriction of death-related religious-cultural rituals; and protective factors including relative support (i.e., family, spouse, friend, partner), tele-support (i.e., mobile phone, internet, social media), positive coping strategies (cognitive, behavioral, and religious-spiritual), and delayed business. The "delayed business" concept was also addressed within protective factors and explained in general terms. Finally, the findings were discussed considering the literature and presented some theoretical and practical implications.

Prolonged grief, emotion regulation and loss-related factors: An investigation based on cognitive and behavioral conceptualization

The study aimed to examine the variables that play a role in the process of prolonged grief within the framework of the cognitive-behavioral model. Participants (N = 475) from Turkey took part in a cross-sectional questionnaire survey. The study used structural equation modeling to test a hypothesized model via AMOS v23. After testing two options, the final model was found to be good fit for the data. Results suggested the importance of adopting a comprehensive approach to prolonged grief interventions which includes the loss- and relationship-related factors as well as emotion regulation difficulties, autobiographic memory characteristics, and the grief cognitions.

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.

Bereavement-related regrets and unfinished business with the deceased

Unresolved relational issues with the deceased have been considered a prominent risk factor for negative bereavement outcomes. However, this area of study has suffered from a lack of conceptual clarity, with some commentators focusing on bereavement-related regret and others focusing on "unfinished business," or lingering or unspoken conflicts with the deceased. This study examined the two concepts in a sample of 229 bereaved individuals, finding them to be overlapping but distinct constructs. Unfinished business occurred more frequently with immediate family and friends and in cases of sudden and violent death of loved ones. Both forms of unresolved issues were associated with bereavement outcome, with the relation between distress over unfinished business and complicated grief symptomatology being particularly robust.

The Unfinished Business in Bereavement Scale (UBBS): Development and psychometric evaluation

Although unresolved issues with the deceased are often targeted in bereavement interventions, understanding of this construct has been hampered by the lack of a psychometrically validated scale to assess it. To address this gap, the Unfinished Business in Bereavement Scale (UBBS) was developed and tested in two samples of bereaved adults (n = 292 and 168). In exploratory and confirmatory factor analyses, the UBBS was found to be composed of two related factors. Items tapping into Unfulfilled Wishes pertained to unspoken affirmations or missed opportunities with the deceased. These experiences often emerged in loving relationships and only became problematic when accompanied by high levels of distress. In contrast, Unresolved Conflict pertained to unaddressed disputes or indiscretions. It primarily occurred in relationships characterized by anxiety and conflict and conferred risk for prolonged grief reactions even when endorsed at moderate levels. Other findings strongly supported the internal consistency, concurrent validity, and incremental validity of the UBBS. Unfinished business and meaning made of loss together accounted for 50-60% of the variance in prolonged grief symptoms. Implications for clinical practice and future research are discussed.

Schema Therapy for Emotional Dysregulation: Theoretical Implication and Clinical Applications

The term emotional dysregulation refers to an impaired ability to regulate unwanted emotional states. Scientific evidence supports the idea that emotional dysregulation underlies several psychological disorders as, for example: personality disorders, bipolar disorder type II, interpersonal trauma, anxiety disorders, mood disorders and post-traumatic stress disorder. Emotional dysregulation may derive from early interpersonal traumas in childhood. These early traumatic events create a persistent sensitization of the central nervous system in relation to early life stressing events. For this reason, some authors suggest a common endophenotypical origin across psychopathologies. In the last 20 years, cognitive behavioral therapy has increasingly adopted an interactive-ontogenetic view to explain the development of disorders associated to emotional dysregulation. Unfortunately, standard Cognitive Behavior Therapy (CBT) methods are not useful in treating emotional dysregulation. A CBT-derived new approach called Schema Therapy (ST), that integrates theory and techniques from psychodynamic and emotion focused therapy, holds the promise to fill this gap in cognitive literature. In this model, psychopathology is viewed as the interaction between the innate temperament of the child and the early experiences of deprivation or frustration of the subject's basic needs. This deprivation may lead to develop early maladaptive schemas (EMS), and maladaptive Modes. In the present paper we point out that EMSs and Modes are associated with either dysregulated emotions or with dysregulatory strategies that produce and maintain problematic emotional responses. Thanks to a special focus on the therapeutic relationship and emotion focused-experiential techniques, this approach successfully treats severe emotional dysregulation. In this paper, we make several comparisons between the main ideas of ST and the science of emotion regulation, and we present how to conceptualize pathological phenomena in terms of failed regulation and some of the ST strategies and techniques to foster successful regulation in patients.

How do attachment dimensions affect bereavement adjustment? A mediation model of continuing bonds

The current study aims to examine mechanisms underlying the impact of attachment dimensions on bereavement adjustment. Bereaved mainland Chinese participants (N=247) completed anonymous, retrospective, self-report surveys assessing attachment dimensions, continuing bonds (CB), grief symptoms and posttraumatic growth (PTG). Results demonstrated that attachment anxiety predicted grief symptoms via externalized CB and predicted PTG via internalized CB at the same time, whereas attachment avoidance positively predicted grief symptoms via externalized CB but negatively predicted PTG directly. Findings suggested that individuals with a high level of attachment anxiety could both suffer from grief and obtain posttraumatic growth after loss, but it depended on which kind of CB they used. By contrast, attachment avoidance was associated with a heightened risk of maladaptive bereavement adjustment. Future grief therapy may encourage the bereaved to establish CB with the deceased and gradually shift from externalized CB to internalized CB.

Unfinished Business in Bereavement

Unfinished business (incomplete, unexpressed or unresolved relationship issues with the deceased) is frequently discussed as a risk factor for chronic and severe grief reactions. However, few empirical studies have examined this construct. The present study aimed to address this gap in the literature by examining the presence and severity of unfinished business as well as common themes of unfinished business reported in open-ended qualitative narratives among a sample of 224 bereaved individuals. In bivariate analyses, self-reported presence of unfinished business and the severity of distress due to unfinished business were both found to be associated with poorer bereavement outcomes. However, after controlling for potential confounds, distress related to unresolved issues with the deceased emerged as a more robust correlate of these outcomes. Qualitative responses were categorized, and the type of reported unfinished business was not significantly related to the degree of unfinished business distress or other bereavement outcomes. These findings provide preliminary justification for bereavement interventions that aim to ameliorate distress related to unresolved relational issues with the deceased.

Bereavement-related regret trajectories among widowed older adults

OBJECTIVES

Although regrets and unfinished business with a deceased spouse are frequently discussed as crucial determinants of one's postloss adjustment, there have been few empirical investigations of bereavement-related regrets. This present study aimed to investigate the longitudinal course of these regrets and their correlates among widowed older adults.

METHODS

Drawing upon information from 201 widowed older adults in the Changing Lives of Older Couples study, this present study used latent class growth analysis to identify unique longitudinal trajectories of regret from 6 to 48 months postloss and examine differences between these trajectories with regard to grief and depressive symptomatology.

RESULTS

Three distinct bereavement-related regret trajectories were identified, characterized by Stable Low Regret, Stable High Regret, and Worsening High Regret. Results revealed that those in the Worsening High Regret group, whose bereavement-related regrets were exacerbated during the study, had the poorest grief outcomes. No differences were observed between these groups with regard to depressive symptoms, indicating that regret may be a unique marker of difficulties in the grieving process.

DISCUSSION

These findings highlight the importance of periodically reassessing bereavement-related regrets (and perhaps other aspects of the continued relationship with the deceased) over time and support the rationale behind interventions designed to facilitate resolution of these issues.

The relationship of child maltreatment and self-capacities with distress when telling one's story of childhood sexual abuse

This study examined the impact of telling one's story of childhood sexual abuse and its relationship with the survivor's self-capacities and history of other child maltreatment. The baseline data were collected from 134 female CSA survivors who were participating in a large intervention study. Participants were given 10 minutes to describe their childhood sexual abuse and completed a post-interview questionnaire assessing post-traumatic stress symptoms and their emotional response. The distress in response to their narrative was both predicted and mediated by the survivors' self-capacities and other forms of child maltreatment beyond child sexual abuse.

Continuing bonds and grief: a prospective analysis

Using data of 56 bereaved individuals, this study examined associations of various manifestations of continuing bonds, assessed at 7-12 months post-loss, with concurrent and prospective (9 months later) symptoms of grief and depression. Among other things it was found that, independent of initial symptom levels, manifestations of continuing bonds differed in their associations with subsequent grief and depression. That is, continuing bonds through recovering memories was a strong predictor of grief but not depression, whereas continuing bonds through the use of the deceased's possessions was a weak predictor of both grief and depression. In part, these findings contradict earlier prospective findings.

Continuing bonds in bereavement: an attachment theory based perspective

An attachment theory based perspective on the continuing bond to the deceased (CB) is proposed. The value of attachment theory in specifying the normative course of CB expression and in identifying adaptive versus maladaptive variants of CB expression based on their deviation from this normative course is outlined. The role of individual differences in attachment security on effective versus ineffective use of CB in coping with bereavement also is addressed. Finally, the moderating influence of type of loss (e.g., death of a spouse vs. child), culture, and religion on type of CB expression within an overarching attachment framework is discussed.

Unresolved grief in combat veterans with PTSD

Clinicians have documented the importance of loss of comrades during combat as a significant source of distress. However, empirical studies have not focused on unresolved grief as a possible outcome of combat experiences. Consequently, unresolved grief has often been treated "after the fact" in the context of treating PTSD and depressive symptoms. In this study, we therefore, sought to demonstrate the prominence of combat-related grief-specific symptoms in a sample of Vietnam veterans being treated for PTSD. Our results indicated that indeed this sample of veterans reported high levels of grief-specific symptoms comparable to that found in bereaved individuals whose spouse had recently died, verifying its prominence as an important component of combat-related stress. Furthermore, grief severity was uniquely associated with losses of comrades during combat whereas no such relationship was shown for trauma or depressive symptoms. The latter finding suggested that in fact higher levels of grief stemmed from interpersonal losses during the war and was not simply an artifact of current general distress level.

Continuing bonds in coping with the death of a husband

This study examined the continuing bond (CB) to the deceased in coping with the death of a husband. Fifteen early-bereaved widows whose husband had died 4 months previously and 15 later-bereaved widows whose husband had died more than 2 years ago were electronically signaled every 3 hours to complete a set of measures that included the PANAS positive and negative mood scales and CB coping. Participants completed these measures 4 times each day for 14 successive days. Following from an attachment theory perspective on the role of CB in providing felt security, it was hypothesized that CB would be effective as a way of coping in mood regulation, but that its effectiveness would be moderated by time since the death. Consistent with predictions, a positive within-person relationship was found between CB coping and positive mood for the later-bereaved group, but not for early-bereaved widows. CB coping was also positively related to negative mood for both early, and later-bereaved widow groups, however. Finally, in a lagged analysis, greater use of CB was predictive of a shift toward more negative mood among early-bereaved widows, but not for later-bereaved widows. The results were discussed in the context of previous literature on the function of CB in adaptation to bereavement.

Continuing bonds and adjustment at 5 years after the death of a spouse

Thirty-nine bereaved individuals completed the Continuing Bonds Scale (CBS), assessing various aspects of the ongoing attachment to the deceased, at 60 months postloss in a longitudinal conjugal bereavement study. They also completed symptom measures at 6, 14, 25, and 60 months postloss. Higher CBS scores were associated with a more elevated grief-specific symptom pattern over the 5-year postloss period. Moreover, those who expressed greater helplessness and less blame toward the deceased during a monologue role-play involving their deceased spouse at 6 months postloss had higher CBS scores. Finally, greater satisfaction in the past relationship with the spouse was predictive of higher CBS scores. The results were discussed in relation to existing literature on the adaptiveness of continuing bonds.

The unrecognised cost of cancer patients' unrelieved symptoms:a nationwide follow-up of their surviving partners

We investigated if a cancer patient's unrelieved symptoms during the last 3 months of life increase the risk of long-term psychological morbidity of the surviving partner. All women (n=506) living in Sweden under 80 years of age, who lost their husband/partner owing to cancer of the prostate in 1996 or of the urinary bladder in 1995 or 1996 were asked to answer an anonymous postal questionnaire, 2-4 years after their loss. The widows' psychological morbidity was associated with the patient's unrelieved mental symptoms. When the patient was perceived to have been very anxious during last three months of life (compared to no observed symptoms) the relative risks for the widows' psychological morbidity were: 2.5 (1.4-4.3) for depression and 3.4 (1.4-8.2) for anxiety. When comparing reports of the patient's pain (much vs no), the relative risks were 0.8 (0.5-1.2) for widowhood depression, and 0.8 (0.4-1.7) for widowhood anxiety. The patients were found to have had adequate access to physical pain control but poor access to psychological symptom control. Efficiency in diagnosing and treating psychological complications of terminally ill cancer patients may not only improve their quality of life but possibly also prevent long-term psychological morbidity of their surviving partners.