Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss

Exploring the Role of Coping Strategies on the Impact of Client Suicide: A Structural Equation Modeling Approach

Client suicide refers to cases where a mental health practitioner is exposed, affected, or bereaved by a client's suicide and is known to have a profound impact on MHPs. The current study investigated the role of coping styles in understanding short- and long-term impact of client suicide. An international sample of 213 mental health practitioners who experienced a client suicide completed a survey on coping strategies (i.e., Brief-COPE) and the impact of traumatic events (i.e., impact of event scale-revised, long-term emotional impact scale and professional practice impact scale). Results indicate coping strategies explain 51% of the short-term, 64% of the long-term emotional and 55% of the long-term professional differences in impact of client suicide. Moreover, while an Avoidant coping style predicted more impact of client suicide, Positive coping and Humor predicted less impact of client suicide. Social Support coping did not predict impact of client suicide. Implications for both research and clinical practice are discussed.

Individual and systemic variables associated with prolonged grief and other emotional distress in bereaved children

Most children confronted with the death of a loved one do not experience persisting psychological problems. However, for some, acute grief reactions develop into prolonged grief disorder (PGD) and other mental health problems. Research findings suggest that bereavement outcomes in children are associated with negative cognitions and avoidant coping and with different parenting behaviours. However, knowledge about factors influencing grief in children is still limited and few studies have examined the relative impact of psychological (individual-level) variables and systemic (family-level) variables in affecting their responses to loss. The aim of the current study was to examine the association of different bereavement outcomes in 8-18 year old children (including levels of self-rated PGD, depression, and posttraumatic stress (PTS)) with sociodemographic variables, individual-level variables (including negative cognitions and anxious and depressive avoidance), and family-level variables (including the severity of caregiver's PGD, depression, and anxiety, and indices of parenting behaviours, rated both by children and by their caregivers). Questionnaire data were used from 159 children plus one of their caregivers, gathered as part of the pre-treatment assessment in a randomized controlled trial. Results showed that most of the children's bereavement outcomes, including PGD severity and PTS severity, were associated with indices of negative cognitions and avoidance behaviours. Caregiver's depression and anxiety showed a very small, yet significant, association with two children's outcomes. Caregiver-rated reasoning/induction (one index of parenting behaviours) showed a small association with children's PTS-related functional impairment. Exploratory analyses indicated that the linkage between parenting behaviour and children's outcomes may be moderated by whether the behaviour comes from father or mother. This is one of the first studies examining how individual cognitive behavioural variables plus the mental health of caregivers and indices of parenting may affect PGD and other outcomes in bereaved children. The findings provide tentative indications that individual and family-level variables influence these outcomes, albeit that more research is urgently needed.

Practitioner perspectives on the use of acceptance and commitment therapy for bereavement support: a qualitative study

BACKGROUND

There is currently a high demand for bereavement support coupled with inconclusive findings as to the efficacy of existing approaches. Acceptance and Commitment Therapy (ACT) aims to improve human functioning and has shown efficacy across a wide range of conditions. ACT may be a promising means of supporting bereaved people, yet evidence on the use of ACT for bereavement support is lacking. The aim of this study is to explore how ACT is currently used for bereavement support and practitioner perspectives of how it helps following bereavement.

METHODS

Semi-structured interviews were conducted online via MS Teams with practitioners experienced in using ACT for bereavement support. Data were analysed thematically guided by a framework approach.

RESULTS

Nine participants were recruited. Three themes were identified: (i) creating psychological space around grief; (ii) using psychological space for value-directed action in the midst of grieving, and (iii) adapting ACT for bereavement support. Practitioners indicated that ACT improves clients' relationship with distressing internal experiences. Metaphors and mindfulness techniques were used to encourage acceptance of grief responses, taking perspective on distressing thoughts and images, and contact with the present moment. Better relationships with distressing experiences were regarded as less psychologically taxing, improving coping and well-being, while providing the psychological space to engage in value-directed action. Values exploration, sometimes using metaphors and exercises, was seen as supporting the bereaved person to rediscover a sense of purpose and engage in meaningful activities alongside their grief. Practitioners used ACT flexibly, integrating other interventions, and adapted ACT to the perceived sensitivities of bereaved people, and age-related and developmental factors.

CONCLUSION

ACT is used to support people who have been bereaved to live effectively with the difficult thoughts and feelings associated with grieving and to enable them to gradually identify, reconnect with, and act in line with their values after loss.

The associations of grief-related rumination with prolonged grief and posttraumatic stress symptoms: A longitudinal study of bereaved after the 2011 terror attack in Norway

After the sudden and violent death of a loved one, many bereaved experience symptoms of prolonged grief (PG) and posttraumatic stress (PTS). The present study investigated the cross-sectional and longitudinal associations of grief-related rumination with PG and PTS symptoms among bereaved parents and siblings after the Utøya terror attack in Norway on 22 July 2011 (N = 110, Mage  = 43.2 years, 59.1% female). Participants' responses on the Rumination Scale, the Inventory of Complicated Grief and the Impact of Event Scale-Revised 28, 40 and 102 months after the loss were analysed. Cross-sectionally and longitudinally, grief-related rumination was positively and strongly linked with PG and PTS symptoms. When controlling for the baseline levels of PG and PTS symptoms and demographics of the sample, grief-related rumination predicted PG symptoms after 12 months but not after 74 months. Further, grief-related rumination predicted significantly the PTS symptoms of avoidance after 12 and 74 months and hyperarousal after 74 months beyond sample demographics and baseline symptoms. The results suggest that grief-related rumination is an important factor in PG and PTS symptoms after traumatic bereavement.

The Role of Emotion Regulation Difficulties and Intrusive and Deliberate Rumination in the Association Between Insecure Attachment and Prolonged Grief

This study investigated the role of emotion regulation difficulties and intrusive/deliberate rumination in the relationship between insecure attachment and prolonged grief symptoms. A total sample of 342 bereaved participants was included in the study. Both anxious and avoidant attachment styles were found to be associated with prolonged grief symptoms, with an avoidant attachment showing a stronger effect. Emotion regulation difficulties and rumination mediated the relationships between attachment styles and prolonged grief symptoms, supporting the proposed mediation model. The study identified specific mediating pathways for anxious and avoidant attachment styles. Additionally, female gender, higher age, unexpected death, and closeness of the relationship with the deceased were significant predictors of prolonged grief symptoms.

Adaptive and harmful autobiographical remembering after the loss of a loved one

Objectives: Remembering one's personal past serves psychosocial functions. Adaptive use of autobiographical memory is related to well-being but little research has focused on grief. We address this in two studies theoretically grounded in the model of reminiscence and health.Method: Participants were adults who were actively grieving, and in both studies, completed the Reminiscence Functions Scale and grief-related measures (i.e. feelings of grief, positive changes in life perspective). Study 1 focused on uses for generally recalling one's past and Study 2 on uses of memories of the deceased.Results: Across studies, self-negative ways of remembering were associated with stronger feelings of grief and also mediated relations between social ways of remembering and grief. Self-positive ways of remembering the deceased (Study 2) were associated with having experienced positive changes in life perspective since the loss.Conclusion: The discussion focuses on how memories of one's personal past are linked to the experience of loss, even years into bereavement.

Cognitive reappraisal, emotional expression and mindfulness in adaptation to bereavement: a longitudinal study

BACKGROUND AND OBJECTIVES

Maladaptive emotion regulation strategies increase prolonged grief and depressive symptoms following bereavement. However, less is known about the role of adaptive emotion regulation strategies in adaptation to loss. Therefore, we examined the concurrent and longitudinal associations of three putative adaptive emotion regulation strategies (cognitive reappraisal, emotional expression, and mindfulness) with prolonged grief and depression symptoms.

DESIGN

A two-wave longitudinal survey.

METHODS

A sample of 397 bereaved Dutch adults (89% female, mean age 54 years) completed validated questionnaires to assess trait cognitive reappraisal, emotional expression, mindfulness and prolonged grief and depression symptoms at baseline (T1) and 344 participants completed symptom measures again six months later (T2).

RESULTS

Zero-order correlations demonstrated that mindfulness, cognitive reappraisal and emotional expression relate negatively to T1 and T2 prolonged grief and depression symptoms. In multiple regression analyses, controlling for relevant background variables, all emotion regulation strategies related negatively to T1 prolonged grief and depression symptoms. In multiple regression analyses, controlling for T1 symptoms and background variables, mindfulness predicted lower T2 depression symptoms.

CONCLUSIONS

Adaptive emotion regulation strategies relate negatively to post-loss psychopathology symptoms, yet only mindfulness longitudinally predicts lower depression symptoms. Dispositional mindfulness may be a protective factor in psychological adaptation to bereavement.

Why Does Grief Hurt?

Abstract. Grief is a major physical and psychological health concern for adults, as well as a key risk factor for depression. The direct and indirect costs of depression in adults place heavy burdens on societal resources. Indeed, bereavement is a stressful and profound life experience, with the grieving process combining reactions to a loss that may originate in complications for bereaved individuals. The goal of this systematic review is to synthesize the findings regarding depression and grief. Studies related to the topic were obtained from multiple databases through rigorous exclusion and inclusion criteria. Only empirical studies with quantitative methodologies were included. Objectives, sample (type of sample, % male, and age), instruments, and main conclusions were extracted from each study. Overall, there are personality and contextual factors that, in addition to affecting depressive reactions following a loss, may also interface with one’s ability to grieve. Furthermore, after the patient’s death, there was a decrease in depressive symptoms over time, indicating that these symptoms are dynamic. Individuals who experience prolonged grief exhibit depressive symptoms, and those who suffer a loss may have depressive symptoms, but in a natural and non-pathological way, that is, sadness and not depression. Depression tends to decrease over time, with the existence of more children and a focus on occupation.

Turkish validity and reliability study of male genital self-image scale (MGSIS)

Objective:

This study, which was carried out in order to determine the Turkish validity and reliability of the “Male Genital Self-Image Scale” in a population sample of Turkish men, is of methodological type.

Methods:

In the study, language, content, construct validity, and reliability methods were used for the intercultural adaptation of the scale. The data collection process of the scale was carried out with 336 men who applied to the Family Medicine Polyclinic of a hospital. In the language and content validity phase, the opinions of experts with technical and cultural knowledge were consulted. The data of the study were collected with the Sociodemographic Characteristics Form and the Male Genital Self-Image Scale.

Results:

As a result of experts evaluation, the Content Validity Ratio value was determined as 0.83. At the stage of construct validity, the suitability of the single-factor model of the items of the Male Genital Self-Image Scale was tested. It was determined that all items contributed significantly to the factor (0.62–0.92). As a result of the Confirmatory Factor Analysis, the measurement model was statistically validated (χ2 = 32.083, p = 0.001, χ2/df = 2.917, RMSEA = 0.076). The Cronbach’s alpha reliability coefficient was calculated as α = 0.92 in the analysis performed to evaluate the internal consistency of Male Genital Self-Image Scale.

Conclusion:

The results of the study revealed that Male Genital Self-Image Scale is a valid and reliable tool to evaluate genital self-image in Turkish men.

Reciprocal Relations of Worry, Rumination, and Psychopathology Symptoms After Loss: A Prospective Cohort Study

Bereavement can precipitate symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder. Targeting repetitive negative thought (i.e., worry, rumination) in treatment may help reduce post-loss psychopathology. Yet, evidence on longitudinal associations of depressive rumination and worry with post-loss psychopathology symptoms has been mixed and the directions of effects are still unclear. Recently bereaved adults (78% female) completed questionnaires assessing depressive rumination (brooding), worry, and depression, prolonged grief and posttraumatic stress symptoms 11 times in 1.5 month intervals. We applied random-intercept cross-lagged panel models (RICLPMs) to examine reciprocal within-person associations between worry and psychopathology symptoms, between rumination and these symptoms, and between worry and rumination. Main findings were that worry showed reciprocal relationships with psychopathology symptoms (although worry did not consistently predict prolonged grief symptoms). Depressive rumination was predicted by psychopathology symptoms, but not vice versa. Worry showed reciprocal relations with depressive rumination. Findings suggest that worry may be part of a downward spiral, enhancing psychopathology symptoms following loss, whereas depressive rumination is solely a consequence of such symptoms.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Does 'Time Heal all Wounds?' The Prevalence and Predictors of Prolonged Grief Among Drug-Death Bereaved Family Members: A Cross-Sectional Study

Despite rising rates of drug-related deaths (DRDs), the consequences of DRDs for bereaved family members are scarcely investigated. This study aimed to estimate the prevalence of prolonged grief (PG) symptoms in bereaved family members after DRDs, identify predictors of PG and examine whether symptom levels decrease with time. A cross-sectional design based on survey data from parents (n = 93), siblings (n = 78), children (n = 24) and other family members (n = 39) was conducted (n = 234). Descriptive analyses, a multivariate linear regression, and ANOVA were performed. 60 family members (26%) suffered from high levels of PG symptoms after DRDs (parents 31.2%, siblings 21.8%, children 20.9%). The strongest associations were found between a high level of symptoms and 'months since the loss', 'suicidal thoughts' and 'withdrawal from others'. The ANOVA analyses showed that time does not always 'heal all wounds', and the bereaved who lost one to 2 years ago had the highest level of PG symptoms.

Reinforcement sensitivity predicts affective psychopathology via emotion regulation: Cross-sectional, longitudinal and quasi-experimental evidence

The current article presents a model wherein reinforcement sensitivity predicts depression and anxiety via trait preferences for concomitant emotion regulation strategies. In Study 1 (N = 593), BAS sensitivity positively predicted reappraisal and BIS sensitivity negatively predicted it. Reappraisal then negatively predicted depression. BIS sensitivity also predicted rumination, which predicted both depression and anxiety. Study 2a confirmed the model developed in Study 1 with an independent sample (N = 513) and examined the relationships longitudinally. While the cross-sectional relationships were generally maintained, reinforcement sensitivity did not predict reappraisal. In Study 2b, participants (N = 218) were assessed a third time one year later, at the onset of the COVID-19 pandemic. During this stressful time, BAS sensitivity did longitudinally predict reappraisal. These studies highlight the role of emotion regulation in mediating the relationship between reinforcement sensitivity and affective pathology, particularly during times of high stress.

Avoidant coping as mediator of the relationship between rumination and mental health among family caregivers of Chinese breast cancer patients

INTRODUCTION

Family caregivers of cancer patients were often referred to the 'forgotten patients', yet little researches have been conducted on their mental health. Rumination might put family caregivers at risk for psychological distress during the caregiving, such as stress and anxiety. The aim of the present study was to explore the relationship between rumination, stress and anxiety among family caregivers of breast cancer patients in China and examine the mediating role of avoidant coping in this relationship.

METHODS

Face-to-face questionnaire interviews were conducted with a sample of 99 caregivers from the public oncology hospital. They were assessed with stress, anxiety, rumination and avoidant coping by Chinese Perceived Stress Scale, Zung's Self-Rating Anxiety Scale, Ruminative Responses Scale and Coping Strategy Indicator. Structural equation modelling was applied to assess the mediation analysis.

RESULTS

The reporting scores of participants indicated the incidence of anxiety was 17.2%. Rumination could directly predict stress (β = 0.58, p < 0.01) and anxiety (β = 0.46, p < 0.01) and also predict stress and anxiety via the mediator of avoidant coping (stress: β = 0.087, p < 0.01; anxiety: β = 0.109, p < 0.01).

CONCLUSIONS

The important role played by family caregivers in supporting breast cancer patients is well recognised. The findings suggested that rumination and avoidant coping may be two critical risk factors for family caregivers of breast cancer developing stress and anxiety. This study highlights the importance of preventing avoidant coping, which plays a critical role for developing interventions for this vulnerable group.

Randomized Clinical Trial of Primary Care Based Online Depression Prevention Intervention: Impact on Adolescent Modifiable Factors and Behaviors

The developmental period of adolescence can pose a risk for the onset of depressive disorders, but is also a time when potentially modifiable factors and behaviors related to depressive episode onset can develop. An online health intervention can provide an opportunity to reach at-risk adolescents in between primary care visits and could impact these modifiable factors and behaviors to support healthy development. We explore the Competent Adulthood Transition with Cognitive-Behavioral, Humanistic, and Interpersonal Therapy (CATCH-IT), a self-directed online cognitive behavioral therapy prevention intervention, and its impact on modifiable factors and behaviors related to: (1) program completion, (2) normative adolescent development, (3) coping, (4) family relations, (5) general health behaviors, and (6) externalizing behaviors, in a primary care sample of adolescents at intermediate to high risk of developing depression. Adolescents were enrolled into either CATCH-IT or Health Education (HE) control group and followed for 24 months. CATCH-IT improved some factors related to program completion (e.g., motivation, recommendation to peers for depression prevention, and physician positive relationship), coping (e.g., perceived behavior change), and family relations (e.g., parental psychological control, sibling relative status) as compared to HE. HE improved normative adolescent development (e.g., health and loss life events) as compared to CATCH-IT. CATCH-IT utilized in primary care may benefit some at-risk adolescents in selective factors and behaviors.

Psychometric properties of the German version of the Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ)

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ) was developed to measure depressive and anxious avoidance behaviors, which, according to cognitive-behavioral models, are supposed to play an important role in the development and maintenance of prolonged grief. The present study aimed to develop a German version of the DAAPGQ and evaluate its psychometric properties and validity within a representative sample of the German general population (N = 2531). The German-language DAAPGQ was developed using a forward-backward translation procedure. Then, a subsample of individuals who reported having lost a significant other (N = 1371) of a representative sample was assessed with the German DAAPGQ, along with information on sociodemographic characteristics, prolonged grief symptom severity (PG-13), general anxiety (GAD-2) and depression (PHQ-2). The factor structure of the DAAPGQ was evaluated using confirmatory factor analyses, reliability by calculating internal consistency on subscale level and convergent validity by correlations between DAAPQG subscale sores with PG-13, GAD-2 and PHQ-2 sum scores. As expected, a two-factor model with correlated latent variables showed good fit to the data, replicating findings from the original version. Internal consistency was high for both subscales (Cronbach’s α .86 and .95, respectively). Convergent validity was established by theoretically expected and statistically significant positive correlations of DAAPGQ subscales with symptom severity of prolonged grief, depression, and anxiety and negative correlations with time since loss. Furthermore, the addition of depressive and anxious avoidance significantly improved the prediction of prolonged grief symptom severity over sociodemographic and loss-related information. In sum, our results suggest that the German-language DAAPGQ is a reliable and valid measure of depressive and anxious avoidance and a useful tool to improve our knowledge on the role of avoidance in prolonged grief. We also provide descriptive data to improve the applicability of the DAAPGQ for individual diagnostics.

Symptoms of prolonged grief disorder as per DSM-5-TR, posttraumatic stress, and depression: Latent classes and correlations with anxious and depressive avoidance

Bereavement may precipitate significant mental health problems. Prolonged grief disorder (PGD) is included in section 2 of the forthcoming DSM-5 text-revision (DSM-5-TR). Research using earlier criteria of disordered grief showed that bereaved people may have distinct symptom patterns-including high, low, and comorbid symptomatology. Building on that work, we used latent class analysis to identity subgroups of bereaved individuals based on their endorsement of symptoms of PGD (per DSM-5-TR), posttraumatic stress, and depression. We also examined if class-membership was associated with socio-demographic and loss-related variables and anxious and depressive avoidance behaviors. Self-reported data were available from 436 people, mostly women, mostly bereaved by the death of their partner or child. Three subgroups were identified, evidencing low symptom levels (34.2%), predominantly PGD symptoms (38.7%), and high symptom levels (27%), respectively. Shorter time since loss, lower education, loss of a partner, and unnatural/violent deaths increased chances of inclusion in the high symptoms class. Anxious and depressive avoidance were lowest in the low symptoms class, higher in the PGD class, and strongest in the high symptoms class. Findings show that PGD per DSM-5-TR is a distinct condition and underscore that reducing avoidance behaviors is important in the treatment of post-loss psychopathology.

Loneliness during the COVID-19 pandemic: change and predictors of change from strict to discontinued social distancing protocols

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic and the social distancing protocols designed to impede transmission of the corona virus have severe mental health consequences. This study examine changes in loneliness in the general adult population when the corona-related social distancing protocols were largely discontinued (T2) following a period of strict protocols (T1), predictors and correlates of these changes, and the associations between loneliness and depression and anxiety symptoms.

DESIGN

In an online survey, 10,061 responded at T1. At T2, these respondents were asked to complete the survey again, and 4936 (49.1%) of them responded.

RESULTS

Loneliness decreased from T1 to T2, but only to a minor extent. Using a multilevel approach, younger age was found to be related to more reduction of loneliness from T1 to T2. Higher health anxiety was found to predict less reduction of loneliness across time. Reduction of maladaptive coping strategies and negative metacognitive beliefs from T1 to T2 were both associated with reduction in loneliness. In turn, reductions in loneliness were associated with reductions of depression and anxiety symptoms.

CONCLUSIONS

The results suggest that health anxiety, maladaptive coping strategies and negative meta-beliefs are potential targets of intervention to alleviate loneliness.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04444115.

Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment

Losing a loved one is one of life's greatest stressors. Although most bereaved individuals navigate through a period of intense acute grief that lessens with time, approximately 10% will develop a prolonged grief condition. This review provides an overview of the course of grief and describes risk factors for developing prolonged grief disorder. The evolution of the prolonged grief disorder diagnosis, including the latest criteria sets for ICD-11 and DSM-5, as well as common comorbid conditions and differential diagnosis are discussed. Clinically useful self-report and clinician-rated measures for assessing symptom constructs and overall prolonged grief disorder severity, evidence-based psychotherapies (such as complicated grief treatment), as well as evidence about pharmacologic approaches are presented. Finally, the authors discuss important future directions, including a potential increase in prolonged grief disorder cases due to the COVID-19 pandemic.

The Relationship Among Anxiety, Depression, and Problematic Smartphone Use in University Students: The Mediating Effect of Psychological Inflexibility

OBJECTIVE

The number of studies that reveal the relationship between problematic smartphone use (PSU) and various health problems is increasing. In this study, we aimed to examine the relationship among PSU, depression, and anxiety and the mediating effect of psychological inflexibility (PI) in this relationship in university students.

METHODS

This study was conducted with 412 university students aged between 18-35 years studying at a state university. All participants completed the Acceptance and Action Questionnaire-II, Beck Depression Inventory, Beck Anxiety Inventory, and Smartphone Addiction Scale-Short Version. PROCESS macro in SPSS was used for mediation analysis.

RESULTS

Our analyses showed that both depression and anxiety were independent predictors of PSU even after controlling for each other. Our findings show that PI is the mediator variable in the effect of depression and anxiety on PSU.

CONCLUSION

Mental health professionals working with problematic smartphone use among university students should consider psychological inflexibility as well as depression and anxiety.

Upward and Downward Counterfactual Thought After Loss: A Multiwave Controlled Longitudinal Study

Counterfactual thoughts, mental simulations about how a situation may have turned out differently (i.e., "if only …, then …"), can reduce mental health after stressful life-events. However, how specific counterfactual thought types relate to post-loss mental health problems is unclear. We hypothesized that self-referenced upward counterfactuals (i.e., "If only I had done …, then the current situation would be better") may serve as cognitive avoidance, thereby perpetuating loss-related distress. Conversely, downward counterfactuals (i.e., "If … had happened, then the current situation could have been [even] worse") may facilitate benefit finding, thereby reducing distress. In a longitudinal survey, self-referent, other-referent, and nonreferent upward counterfactuals, and nonreferent downward counterfactuals were assessed at baseline. Prolonged grief and depression symptoms were assessed at baseline, and 6- and 12-month follow-ups. Multiple regression analyses assessed associations between counterfactual thoughts and symptom levels in 65 recently bereaved people who generated counterfactual thoughts about the loss-event. Moderator analyses assessed the unicity of significant effects in the previous step, by comparing these effects in 59 people generating loss-related counterfactuals with those in 59 propensity-score matched participants generating counterfactuals about other negative life-events. Multivariate analyses showed that nonreferent upward counterfactuals were uniquely strongly positively associated with prolonged grief and depression symptoms concurrently. Self-referent upward counterfactuals were uniquely positively associated with prolonged grief and depression symptoms longitudinally. Moderator analyses confirmed that thinking about how one's (in)actions could prevent a death uniquely exacerbated prolonged grief and depression severity. Prolonged grief treatment may be improved by targeting self-blame and guilt.

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.

Loneliness and Social Distancing During the COVID-19 Pandemic: Risk Factors and Associations With Psychopathology

Background: The mitigation strategies employed against the COVID-19 pandemic have severe mental health consequences. In particular, as a result of the social distancing protocols, loneliness is likely to increase. This study investigates (a) potential risk and resilience factors for loneliness in the Norwegian population during the strict social distancing non-pharmacological interventions (NPIs) implemented against the pandemic and (b) the associations between loneliness and psychopathology symptoms. Methods: A survey was disseminated online to the adult Norwegian population when strict social distancing measures had been implemented for 2 weeks. The resulting sample of 10,061 respondents was unproportionate in terms of gender and educational level and thus sensitivity analyses were conducted. The levels of loneliness were compared across demographic sub-groups, and regression analyses were conducted to identify potential risk and resilience factors for loneliness and associations between loneliness and psychopathology symptoms. Results: Among the stable factors, being single and having a psychiatric diagnosis were related to more loneliness with small effect sizes. Among the state risk factors, more rumination and worry in general were associated with stronger loneliness, showing a medium effect size. Among the coping behaviors examined, doing new things at home not done otherwise was negatively related to loneliness, with a small effect size. Loneliness was associated with both depression and anxiety with small effect sizes when all potential confounders and psychiatric diagnosis were controlled for. The relationship to depression was more marked than the relationship to anxiety. Conclusions: The findings suggest that singles and those with a psychiatric diagnosis were most affected by loneliness during the implementation of social distancing measures to impede the coronavirus. The results support the link between loneliness and depression and anxiety symptoms. The results of the analysis of potential risk and resilience factors point to intervention targets for reducing loneliness during pandemic crises.

How Do Drug-Death-Bereaved Parents Adjust to Life Without the Deceased? A Qualitative Study

Knowledge about how bereaved persons grieve can enhance quality in providing the support and potential services that they need. We aimed to identify ways in which drug-death-bereaved Norwegian parents go on with their lives and what inhibits or promotes adaptation during their grieving. Reflexive thematic analysis was used to analyze 14 semistructured in-depth interviews. We generated three themes: (I) processing grief emotions, (II) proactive coping, and (III) giving and receiving support and assistance. Processing guilt rumination, reflections on blame and a burden of grief emotions characterized grieving early on. Using cognitive strategies and functional-support-giving were found to be the most frequently used strategies. Oscillation between processing stressors and reorientation to the world promoted adjustment to ongoing life. We discuss characteristics of parents who struggle to reorient and outline important implications for policy and practice.

Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression

OBJECTIVES

Acceptance and Commitment Therapy (ACT) proposes that cognitive fusion and experiential avoidance are inter-related processes underpinning distress. This study investigated whether worry, rumination, and stressful life events on the one hand and anxiety and depression on the other hand were mediated by cognitive fusion and experiential avoidance (bidirectional serial association).

DESIGN

A questionnaire design was conducted cross-sectionally in a clinical sample (study 1; N = 57) and cross-sectionally and longitudinally in a non-clinical student sample (study 2; N = 106 and N = 97 respectively).

METHODS

Participants completed measures of worry, rumination, stressful life events (predictors), cognitive fusion, experiential avoidance (mediators), anxiety, and depression (outcomes) at T1. In study 2, anxiety and depression were measured again 6 weeks later.

RESULTS

In the clinical sample, the bidirectional relationship between experiential avoidance and cognitive fusion accounted for a significant proportion of the association between rumination and depression, and stressful life events and anxiety and depression. The association between worry and anxiety was mediated by cognitive fusion → experiential avoidance only. In the non-clinical sample, in both cross-sectional and longitudinal analyses, cognitive fusion independently mediated the association between predictors and outcomes, as well as the experiential avoidance → cognitive fusion pathway.

CONCLUSIONS

The bidirectional association between cognitive fusion and experiential avoidance was most predictive of distress in the clinical sample. In the non-clinical sample, cognitive fusion and the experiential avoidance → cognitive fusion pathway demonstrated more explanatory value. Given the cross-sectional nature of most of the data, the findings provide theoretical (as opposed to empirical) support for the models tested.

PRACTITIONER POINTS

Interventions designed to reduce cognitive fusion may be a useful early intervention for sub-clinical anxiety and depression. Interventions focused on reducing both cognitive fusion and experiential avoidance may be helpful for individuals presenting with clinical anxiety and depression. Individuals presenting with particularly high levels of experiential avoidance may benefit from initial work defusing from difficult thoughts, as an inroad for reducing experiential avoidance, anxiety, and depression. Likewise, those with rigid cognitive fusion may benefit from initial work around acceptance skills to create a context that better supports defusion.

Attachment Style, Complicated Grief and Post-Traumatic Growth in Traumatic Loss: The Role of Intrusive and Deliberate Rumination

OBJECTIVE

The present study examines the effects of attachment styles on the grief response and the indirect effect of rumination in parents who lost a child in the Sewol Ferry accident.

METHODS

Bereaved parents (n=81) completed self-report questionnaires evaluating their attachment style (Experience in Close Relationship-Short form), traumatic loss related rumination (Event-Related Rumination Inventory), degree of complicated grief (Inventory of Complicated Grief), and post-traumatic growth (Post-Traumatic Growth Inventory). Data were analyzed using correlation analysis, structural equation modeling, and bootstrapping.

RESULTS

The indirect effect of event-related intrusive rumination was significant in the relationship between attachment avoidance and complicated grief. The path from attachment avoidance to post-traumatic growth via deliberate rumination was not significant. With respect toattachment anxiety and post-traumatic growth, the indirect effect of deliberate rumination was significant. But the indirect effect of intrusive rumination was not significant in the relationships among attachment anxiety, complicated grief, and post-traumatic growth.

CONCLUSION

Individuals with attachment anxiety could obtain post-traumatic growth via deliberate rumination. By contrast, attachment avoidance was associated with the risk of maladaptive grief. Grief interventions should account for individual differences in attachment styles through interventions that manage intrusive rumination and strengthen deliberate rumination.

Symptoms of prolonged grief, posttraumatic stress, and depression in recently bereaved people: symptom profiles, predictive value, and cognitive behavioural correlates

PURPOSE

Prior latent class analyses (LCA) have focused on people who were bereaved more than 6 months earlier. Research has yet to examine patterns and correlates of emotional responses in the first few months of bereavement. We examined whether subgroups could be identified among very recently (≤ 6 months) bereaved adults, based on their endorsement of symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Associations of class membership with overall disturbed grief, PTSD, and depression-assessed concurrently and at 6 months follow-up-were examined. Furthermore, we examined differences between classes regarding socio-demographics, loss-related, and cognitive behavioural variables.

METHODS

PGD, PTSD, and depression self-report data from 322 Dutch individuals bereaved ≤ 6 months earlier were subjected to LCA; N = 159 completed the follow-up assessment. Correlates of class membership were examined.

RESULTS

Three classes were identified: a low symptom class (N = 114; 35.4%), a predominantly PGD class (N = 96; 29.8%), and a high symptom class (N = 112; 34.8%). PGD, PTSD, and depression scores (assessed concurrently and at 6 months follow-up) differed significantly between classes, such that low symptom class < predominantly PGD class < high symptom class. Being a woman, younger, more recently bereaved, experiencing deaths of a partner/child and unnatural losses, plus maladaptive cognitions and avoidance behaviours were associated with membership of the pervasive symptom classes.

CONCLUSION

In the first 6 months of bereavement, meaningful subgroups of bereaved people can be distinguished, which highlights the relevance of early detection of people with elevated bereavement-related distress and offering them preventive interventions that foster adaptation to loss.

Wish you were here: The Dutch, German, and English Yearning in Situations of Loss Short Form

Objective(s)

Yearning, a hallmark of grief disorders, relates to rumination and potentially to cognitive avoidance. We developed an 8‐item short form of the only existing validated yearning measure, the Yearning in Situations of Loss Scale (YSL), to improve its validity and administration ease.

Method

Cross‐sectional surveys were conducted among bereaved Dutch (N = 313) and German (N = 235) community samples and an American treatment‐seeking sample (N = 95). All samples completed the YSL, and community samples additionally measures of rumination, loss‐related avoidance, complicated grief (CG), and depression.

Results

A one‐factor model provided a good fit to the YSL Short Form (YSL‐SF) in the community samples. A two‐factor structure (cognitive and emotional yearning)best fitted the YSL‐SF in the treatment‐seeking sample. YSL‐SF scores correlated positively with rumination, loss‐related avoidance, and with CG symptoms whilst controlling for rumination and loss‐related avoidance.

Conclusion

The YSL‐SF appears an easy‐to‐administer and valid measure of yearning after bereavement.

A systematic review of studies describing the influence of informal social support on psychological wellbeing in people bereaved by sudden or violent causes of death

BACKGROUND

Whilst any type of bereavement can be traumatic, bereavement through violent or sudden causes is associated with more severe negative health and wellbeing outcomes compared to other types of loss. Social support has been found to have a positive impact on wellbeing after traumatic events in general. However, this association appears to be less consistently demonstrated in studies that focus on bereavement, and the literature in this area has not yet been systematically reviewed. This study aimed to review the international literature to examine systematically whether there is an association between informal social support from family and friends after bereavement through sudden and/or violent causes and post-bereavement wellbeing.

METHODS

We conducted a systematic search for quantitative studies that tested for an association between social support and any outcome related to wellbeing after a sudden and/or violent loss. Included studies were assessed for quality, and findings were reported using the approach of narrative synthesis. The review was pre-registered on Prospero (registration number CRD42018093704).

RESULTS

We identified 16 papers that met inclusion criteria, 11 of which we assessed as being of good or fair quality and 5 as poor quality. Fifteen different wellbeing outcomes were measured across all studies. We found consistent evidence for an inverse association between social support and symptoms/presence of depression, predominantly consistent evidence for an inverse association between social support and symptoms/presence of post-traumatic stress disorder (PTSD), and conflicting evidence for an inverse association between social support and symptoms/presence of complicated grief.

CONCLUSIONS

Our systematic review identified evidence to suggest that social support after sudden or violent bereavement is associated with a reduced severity of depressive and PTSD symptoms. Further longitudinal research is needed to explore potential causality in this relationship, widening the focus from common mental disorders to include other mental illnesses, wellbeing outcomes, and suicide-related outcomes after bereavement. There is also a need for consensus on the conceptualisation and measurement of social support. Our findings imply that interventions to improve access to and quality of social support may reduce the burden of mental illness after bereavement, and may therefore be worth investing in.

Do Coping Strategies Differentially Mediate the Relationship Between Emotional Closeness and Complicated Grief and Depression?

Although complicated grief (CG) following the death of a loved one has traditionally been viewed as avoidance-driven, recent research implicates approach behavior. Researchers have investigated how coping styles predict CG; however, emotional closeness remains unexamined. This study investigated the differential relationship of approach- and avoidance-focused coping on CG and depressive symptoms. Bereaved adults ( n = 340) completed questionnaires about their loss, coping styles, CG, and depression. Results suggest that approach-, but not avoidance-, focused coping mediates the relationship of emotional closeness on CG, while emotional closeness of the relationship had no direct impact on depressive symptoms. This suggests closeness of the relationship plays a unique role in CG.

How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement

Repetitive negative thought plays an important role in the maintenance of mental health problems following bereavement. To date, bereavement researchers have primarily focused on rumination (i.e., repetitive thought about negative events and/or negative emotions), yet the interest in worry (i.e., repetitive thought about uncertain future events) is increasing. Both cognitive processes potentially lead to poorer adaptation to bereavement by contributing to loss‐related avoidance and behavioural avoidance of activities. The current study aims to establish the differential associations of rumination and worry with symptoms of depression and prolonged grief and clarify if avoidance processes mediate the associations of rumination and worry with symptom levels. Four hundred seventy‐four recently bereaved adults (82% female) filled out questionnaires assessing rumination, worry, loss‐related and behavioural avoidance, and depression and prolonged grief symptoms. Rumination and worry were both uniquely associated with depression and prolonged grief symptoms. Compared with worry, rumination related more strongly to prolonged grief symptoms, whereas correlations of both cognitive styles with depression symptoms did not differ. Loss‐related avoidance and behavioural avoidance partially mediated the associations of rumination and worry with prolonged grief symptoms. Behavioural avoidance partially mediated the associations of rumination and worry with depression symptoms. Findings suggest that exposure and behavioural activation may be effective interventions to reduce repetitive thinking and psychopathology after bereavement.

Shame, guilt, and pride after loss: Exploring the relationship between moral emotions and psychopathology in bereaved adults

BACKGROUND

Self-blame following bereavement has been implicated in the development of post-loss psychopathology. However, prior studies have not distinguished between the emotions of shame versus guilt. This study examined the cross-sectional associations among bereavement-related shame, bereavement-related guilt, and two mental disorders that commonly arise after bereavement: complicated grief and depression. In addition, exploratory analyses examined the associations between bereavement-related pride and post-loss psychopathology.

METHODS

Participants included 92 bereaved adults who experienced the death of a family member at least one year prior to the study. Participants completed self-report measures of complicated grief symptoms, depression symptoms, shame, guilt, and pride.

RESULTS

Shame and guilt were positively correlated with complicated grief and depression symptoms. When controlling for their shared variance, only shame remained a significant predictor of post-loss psychopathology. Follow-up analyses indicated that the effect of guilt on psychopathology depended on the level of shame, and vice versa. At low shame, guilt predicted psychopathology; however guilt did not predict psychopathology at moderate to high shame. At low to moderate guilt, shame predicted psychopathology; however shame did not predict psychopathology at high guilt. Pride negatively predicted depression symptoms, but not complicated grief symptoms, when we controlled for shame and guilt.

LIMITATIONS

Limitations include the cross-sectional design and modest sample size.

CONCLUSIONS

Our analyses identify shame as the more pathogenic moral emotion for bereaved adults. However, whereas guilt in the absence of shame is often considered adaptive, we found that guilt predicted greater psychological distress at low levels of shame in this sample.

Changes in typical beliefs in response to complicated grief treatment

BACKGROUND

Prolonged grief disorder (PGD) is a new diagnosis in the 11th edition of the International Classification of Diseases, estimated to affect 1 in 10 bereaved people and causing significant distress and impairment. Maladaptive thoughts play an important role in PGD. We have previously validated the typical beliefs questionnaire (TBQ), which contains five kinds of thinking commonly seen in PGD: protesting the death, negative thoughts about the world, needing the person, less grief is wrong, and grieving too much. The current paper examines the role of maladaptive cognition as measured by the TBQ in PGD and its change with treatment.

METHODS

Among participants in a multisite clinical trial including 394 adults, we examined (a) the relationship between maladaptive thoughts at baseline and treatment outcomes, (b) the relationship between maladaptive thoughts and suicidality at baseline and posttreatment, and (c) the effect of treatment with and without complicated grief therapy (CGT) on maladaptive thinking.

RESULTS

TBQ scores were associated with treatment outcomes and were strongly related to suicidal thinking before and after treatment. TBQ scores showed significantly greater reduction in participants who received CGT with citalopram versus citalopram alone (adjusted mean standard error [SE] difference, -2.45 [0.85]; p = .004) and those who received CGT with placebo versus placebo alone (adjusted mean [SE] difference, -3.44 [0.90]; p < .001).

CONCLUSIONS

Maladaptive thoughts, as measured by the TBQ, have clinical and research significance for PGD and its treatment.

"If only…": Counterfactual thinking in bereavement

When grief over the death of a loved one becomes complicated, protracted and circular, ruminative counterfactual thinking in which the bereaved relentlessly but vainly seeks to somehow reverse the tragedy of the loss often plays a contributory role in sustaining the person's suffering. In this article we summarize the growing evidence implicating this cognitive process in interfering with meaning reconstruction following loss, and identify four foci for counterfactual, "if only" cognition, directed at the self, the deceased, relevant others, or the circumstances of the death itself. We then illustrate each with an actual case vignette, along with approaches to resolving, dissolving, mitigating, or redirecting such rumination, and conclude with a general principle of practice for other therapists whose clients struggle with similarly anguished and entrenched counterfactual preoccupations.

Loss in the Life Story: Remembering Death and Illness Across Adulthood

The experience of loss has not often been studied in the life story literature. Life disruption when loss of a loved one occurs may make loss events distinct, even from other challenges, when recalled. Optimally, individuals incorporate such events into their life story in a way that allows them to reflect positively on their life overall. We suggest that telling narratives that represent loss as leading to personal growth or as highlighting one’s connectedness to others may allow a positive view of life overall. In contrast, ruminating may signal a lack of meaningful integration of the event. The current study investigates personal growth from, communion in, and rumination about memories of past loss events. It also determines how these factors relate to positive reflection on one’s life overall. Age was explored as a moderator of these relations. Participants (29 younger adults, 40 older adults) narrated an autobiographical loss event and, for comparison, a non-loss challenging life event and a neutral event. Narratives were self-rated for rumination and extent of resultant personal growth, and reliably content-coded for themes of communion. Participants also completed a measure of positive reflection on their life. Loss narratives resulted in more personal growth and contained more communion themes than other challenging or neutral events. Greater loss-related personal growth predicted more positive life reflection for younger adults. How individuals recall and incorporate loss into their life story may relate differentially to psychosocial outcomes in different life phases.

An investigation of approach behaviour in Prolonged Grief

Prolonged Grief (PG) is recognized as a potentially debilitating post-bereavement syndrome. Theoretical models of PG highlight the importance of both approach and avoidance behaviours in maintaining the syndrome. Research to date has focussed primarily on investigating avoidance in response to loss reminders. Comparatively few studies have indexed approach behaviours in PG. We use a quasi-experimental paradigm to simultaneously examine approach and avoidance behaviours to reminders of the deceased. Fifty-five bereaved individuals with and without PG responded to stimuli showing the deceased's name, an attachment figure's name, a neutral name, or a letter string, by pulling or pushing a joystick according to a whether the stimuli was a word or not. Concurrent visual feedback created the illusion that the images were either approaching or receding from the participant. Participants with PG were quicker to pull than push the three name stimuli, with quicker pulling of the deceased and attachment name than the neutral name. Non-PG participants responded more quickly to the attachment name but evidenced no relative approach or avoidance of any stimuli. Findings provide behavioural evidence about approach behaviour in PG, and are discussed with references to models that recognise the role of yearning for the deceased in PG.

Rumination in bereaved parents: Psychometric evaluation of the Swedish version of the Utrecht Grief Rumination Scale (UGRS)

Background

Bereaved parents may be at higher risk to develop persistent, severe and disabling grief, termed prolonged grief. Grief rumination, repetitive thinking about the causes and consequences of the loss, is a malleable cognitive process that maintains prolonged grief. Grief rumination can be measured with the Utrecht Grief Rumination Scale (UGRS). The present study aimed to examine the psychometric properties of the new Swedish version of the UGRS in a sample of bereaved parents.

Methods

A Swedish nationwide postal survey including measures of demographic and loss-related variables, grief rumination (UGRS), and symptoms of prolonged grief, posttraumatic stress, anxiety, depression, and insomnia, was completed by 226 parents (133 mothers and 93 fathers) who lost a child to cancer in the past five years. Psychometric properties of the UGRS were examined through confirmatory factor analyses (CFA), reliability analyses, and assessment of UGRS score associations with symptoms of prolonged grief, posttraumatic stress, depression, anxiety, and insomnia.

Results

The internal consistency of the Swedish UGRS was good. The CFA yielded an acceptable fit for a two-factor hierarchical model with five sub-factors. Grief rumination was positively associated with all psychopathology symptom measures. Higher scores on UGRS were found in parents with possible prolonged grief disorder compared to those without (d = 1.47). Moreover, the Swedish UGRS was associated with prolonged grief symptoms over and above loss-related and demographic variables and other psychopathology symptoms.

Conclusions

The Swedish UGRS demonstrated good psychometric properties, which supports its use as a measure to assess grief rumination in Swedish bereaved parents in research and practice.

Ongoing monitoring of mindwandering in avoidant grief through cortico-basal-ganglia interactions

An avoidant grief style is marked by repeated and often unsuccessful attempts to prevent thinking about loss. Prior work shows avoidant grief involves monitoring the external environment in order to avoid reminders of the loss. Here we sought to determine whether avoidant grievers also monitor the internal environment in attempts to minimize conscious awareness of loss-related thoughts. Individuals bereaved of a first-degree relative, spouse or partner within the last 14 months participated in a functional magnetic resonance imaging (fMRI) study (N = 29). We first applied machine learning to train neural patterns for attentional control and representation of the deceased (N = 23). The attentional pattern was trained using fMRI data from a modified Stroop task assessing selective attention to reminders of the deceased. The representational pattern was trained using fMRI data from a task presenting pictures and stories of the deceased. We observed spontaneous fluctuations in these processes occurring during a neutral mindwandering fMRI task (N = 27). At higher levels of avoidant grieving, activation of attentional control disrupted the relationship between the representational process and thoughts of loss. These findings show that avoidant grief involves attentional control to reduce the likelihood that deceased-related representations reach full conscious awareness.

A pilot randomised controlled trial of metacognitive therapy for prolonged grief

OBJECTIVES

Prolonged grief disorder is associated with significant distress and impairment and thus efforts to improve treatments are essential. The present pilot study tested the efficacy and feasibility of group Metacognitive Grief Therapy (MCGT) designed specifically for prolonged grief symptomatology to reduce the psychological distress and impaired function resulting from bereavement.

DESIGN/PARTICIPANTS

Twenty-two bereaved adult participants with prolonged grief symptomatology were randomised to a wait-list control (n=10) or an intervention condition (n=12) with a 3-month and 6-month follow-up. The wait-list control group was offered treatment after the post-test assessment.

INTERVENTION

Participants attended six group MCGT sessions that ran for 2 hours per week.

OUTCOME MEASURES

A primary outcome measure of prolonged grief symptomatology and secondary outcome measures of depression, anxiety, rumination, metacognitive beliefs and quality of life were taken pretreatment and post-treatment for both groups and at the 3-month and 6-month follow-up for the intervention group. A Generalised Linear Mixed Model was used to assess treatment efficacy.

RESULTS

Post-treatment intent-to-treat analyses showed MCGT reduced prolonged grief symptomatology (Cohen's d=1.7), depression (d=1.3), anxiety (d=0.8), stress (d=1.0), rumination (d=0.9) and increased quality of life (d=0.6), and these effects were maintained at the 3-month and 6-month follow-ups. No prepost between-group differences were found in metacognitive beliefs. However, a large significant effect was identified at the 3-month and 6-month follow-ups (d=1.0).

CONCLUSION

The results show promise for the utility of group MCGT for reducing psychological distress and promoting quality of life. Additionally, the results underscore the need for a full randomised controlled trial of group MCGT, which may be an important addition to the treatment armamentarium available to support people with prolonged grief.

TRIAL REGISTRATION NUMBER

ACTRN12613001270707; Results. ORIGINAL PROTOCOL: BMJ Open 2015;5:e007221. doi:10.1136/bmjopen-2014-007221.

Self-generated Unconscious Processing of Loss Linked to Less Severe Grieving

BACKGROUND

The intense loss processing that characterizes grieving may help people to adapt to the loss. However, empirical studies show that more conscious loss-related thinking and greater reactivity to reminders of the deceased correspond to poorer adaptation. These findings raise the possibility that loss processing that is unconscious rather than conscious and is self-generated rather than reactive may facilitate adaptation. Here, we used machine learning to detect a functional magnetic resonance imaging (fMRI) signature of self-generated unconscious loss processing that we hypothesized to correlate with lower grief severity.

METHODS

A total of 29 subjects bereaved within the past 14 months participated. Participants performed a modified Stroop fMRI task using deceased-related words. A machine-learning regression, trained on Stroop fMRI data, learned a neural pattern for deceased-related selective attention (d-SA), the allocation of attention to the deceased. Expression of this pattern was tracked during a subsequent sustained attention fMRI task interspersed with deceased-related thought probes (SART-PROBES). d-SA pattern expression during SART-PROBES blocks without reported thoughts of loss indicated self-generated unconscious loss processing. Grief severity was measured with the Inventory for Complicated Grief.

RESULTS

d-SA expression during SART-PROBES blocks without conscious deceased-related thinking correlated negatively with Inventory for Complicated Grief score (r₂₅ = -.711, p < .001, 95% confidence interval = -0.89 to -0.42), accounting for 50% of variance. This relationship remained significant independent of demographic correlates of Inventory for Complicated Grief (B₂₅ = -30, t = -2.64, p = .02, 95% confidence interval = -56.2 to -4.6). Unconscious d-SA pattern expression also correlated with activity in dorsolateral prefrontal cortex and temporal parietal junction during the SART-PROBES (voxel: p < .001, cluster: p < .05).

CONCLUSIONS

Self-generated unconscious loss processing correlated with reduced grief severity. This activity, supported by a cognitive social neural architecture, may advance adaptation to the loss.

Grief and Avoidant Death Attitudes Combine to Predict the Fading Affect Bias

The fading affect bias (FAB) occurs when unpleasant affect fades faster than pleasant affect. To detect mechanisms that influence the FAB in the context of death, we measured neuroticism, depression, anxiety, negative religious coping, death attitudes, and complicated grief as potential predictors of FAB for unpleasant/death and pleasant events at 2 points in time. The FAB was robust across older and newer events, which supported the mobilization-minimization hypothesis. Unexpectedly, complicated grief positively predicted FAB, and death avoidant attitudes moderated this relation, such that the Initial Event Affect by Grief interaction was only significant at the highest 3 quintiles of death avoidant attitudes. These results were likely due to moderate grief ratings, which were, along with avoidant death attitudes, related to healthy outcomes in past research. These results implicate complicated grief and death avoidant attitudes as resiliency mechanisms that are mobilized during bereavement to minimize its unpleasant effects.