Validation of the Portuguese version of the Integration of Stressful Life Experiences Scale (ISLES) in a sample of bereaved individuals

The Integration of Stressful Life Experiences Scale (ISLES) evaluates the ability to integrate stressful experiences into one's meaning system. The present study developed and validated a version of this scale for a bereaved Portuguese-speaking population, utilizing a sample of 242 adults who had lost a significant other to diverse causes of death. The sample was predominantly female, educated, married, or in consensual unions, and actively employed. Confirmatory factor analysis revealed a two-factor structure, consisting of 13 items, showing adequate local and global goodness-of-fit and supporting the proposed original structure. Convergent evidence based on internal structure was found for the two dimensions (Comprehensibility and Footing in the World). Regarding reliability, Cronbach's alpha and McDonald's omega computed for each factor showed good internal consistency and the average inter-item correlation was considered satisfactory. This psychometric support for ISLES underscores its relevance in enhancing the knowledge of meaning-making processes in the Portuguese context.

Experiences of Fathers in Norway Attending an Online Course on Therapeutic Writing After the Death of a Child

After the unexpected death of a child, bereaved parents require prompt access to helpful support systems. Online therapeutic writing courses can make such support accessible. Because few studies have included bereaved fathers as participants, we explored the experiences of fathers whose children died unexpectedly and who were part of an online course of therapeutic writing in Norway. We piloted two courses (group 1, six weeks, n = 9; group 2, 5 weeks, n = 5). We describe our methodological considerations for using poetic representations in qualitative health research and present four poetic representations based on fieldwork notes written by the principal investigator. Then, we triangulate and narratively analyze them together with two collective poems written by participants from each group; excerpts of the writings from two fathers, one per group; evaluation surveys (n = 4; n = 3); and, anonymous check-out journaling from the second group (n = 3). Resistance was a salient feature of our participants' grief, and writing enabled them to both be in contact with their emotional world and process difficult emotions as they looked for meaning despite the death of their children. Those who attended the most classes perceived the course as transformative, being part of an ongoing self-exploration, and a possibility to continue and strengthen the bond with their children. Our findings mirror the complexities of the grief experiences of fathers, giving account of their need to find a rhythm to dive into their emotional world, the importance of peer support, and the value of diversifying intervention techniques to meet individual needs and preferences.

Prolonged grief disorder: A bibliometric analysis

Prolonged Grief Disorder (PGD) has become a subject of increased interest among both researchers and practitioners, owing both to its recent inclusion in the DSM-5-TR and the growing evidence of widespread complications of bereavement in the context of the COVID-19 pandemic. From a set of 467 studies obtained from the Scopus database during the period 2009 to 2022, the present research provides bibliographic data on the most influential authors on the subject, most relevant journals based on the number of documents published, a keyword analysis of the focus of this work, and an overall characterization of the scientific literature on PGD. The Biblioshiny application along with VOSviewer software was used for the analysis and visual depiction of the results. Both the scientific and applied implications of this analysis are discussed.

Meaning reconstruction 70 years later: Processing older adults' unfinished business in a drama therapy group

Unfinished business (UB), when individuals appraise their relationship with others or themselves as incomplete or unresolved, entails difficult emotions such as regret, remorse, and guilt. UB is often associated with bereavement and is considered to be a predictor of complicated grief. Here we report two case studies describing the processing of the sudden death of a significant other in the context of a randomized controlled study of 12-week drama therapy groups for older adults. The intervention followed the format of Playback Theater, an improvised form of theater based on personal stories, and a life review paradigm. A mixed-methods approach explored the course of individual therapy within the group and potential mechanisms of change. The participants completed mental health questionnaires in a pre-post-follow-up design. The qualitative data included video recordings and postintervention interviews. One participant reported a clinically significant (CS) change in depressive symptoms and psychological well-being on the post and follow-up measurement indices. The second reported a CS change in self-esteem and relationship satisfaction at the end of the intervention, but not at follow-up. The findings suggest that the drama therapy contributed to the resolution of UB through restorative work in the three domains defined in meaning reconstruction theory: the "event story" of the loss, the "back story" of the relationship with the deceased, and the "personal story" of self. The results point to the need for additional research on meaning reconstruction in the context of drama therapy and encourage the broader application of performative techniques to treat complicated bereavement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Grief Impairment Scale: A biopsychosocial measure of grief-related functional impairment

Though most mourners are resilient, a minority of the bereaved experience disabling grief accompanied by clinically significant impairment in important areas of functioning. Although impairment measures exist, they have notable limitations in the context of bereavement. Therefore, the objective of this study was to develop and evaluate the Grief Impairment Scale (GIS), which was designed to identify the impact of grief on biopsychosocial functioning. The resulting 5-item scale, which was based on 363 adults who are struggling with grief, demonstrated solid reliability, factorial validity, and convergent and divergent validity with correlations with measures of impairment, prolonged grief, and psychological distress. The GIS also measures grief-related functioning equivalently across demographic groups and satisfactorily discriminates between persons with and without impairment using an optimized cut score of ≥ 9 (79% sensitivity and 74% specificity). These results provide preliminary support for the GIS as a flexible tool for clinical research and practice.

Adaptation of the Spanish Grief and Meaning Reconstruction Inventory: An Initial Validation and Network Analysis

The current study was conducted to adapt the Grief and Meaning Reconstruction Inventory (GMRI) into Spanish and to establish its psychometric properties in a group of 202 mourners seeking treatment in Spain. A confirmatory factor analysis established that the Spanish GMRI yielded eight factors, displaying strong reliability and convergent validity, through the scale's inverse correlation with the Inventory of Complicated Grief and various measures of psychological distress, explaining a 48% of the variance of the former measure. A network analysis suggested that sense-making could play a central role in meaning-making during bereavement.

Restorative Retelling for Processing Psychedelic Experiences: Rationale and Case Study of Complicated Grief

Rationale

Many psychedelic experiences are meaningful, but ineffable. Engaging in meaning-making regarding emerging symbolic content and changing previous schemas have been proposed as mechanisms of change in psychedelic therapy.

Objective

Firstly, we suggest the implementation of a Restorative Retelling (RR) technique to process and integrate the psychedelic experience into autobiographical memory, in a way that fosters meaning-making. We also show how ayahuasca has the potential to evoke key psychological content in survivors, during the process of grief adjustment following the death of a loved one.

Methods

The rationale for the implementation of RR to process psychedelic experiences and a case study of a woman suffering from Complicated Grief (CG) after her mother's suicide are presented.

Results

Evaluations conducted before the ayahuasca experience and after RR suggest the effectiveness of ayahuasca and RR in reducing symptoms of CG and psychopathology.

Conclusion

This case report illustrates an effective adaptation of the RR technique for processing the psychedelic experience. The significance of the study and its limitations are discussed.

Unfinished business and self-blaming emotions among those bereaved by a COVID-19 death

In view of the mounting death toll of COVID-19 worldwide and the complicating circumstances that commonly accompany such losses, we studied the grief experiences of 209 adult mourners who lost a loved one to coronavirus with a focus on self-blaming emotions and unresolved issues with the deceased. We found universal endorsement of one or more forms of self-blame (guilt, regret, shame) or unfinished business (UB), with over one-third of mourners endorsing all four experiences. Those having a closer relationship to the deceased reported both greater distress over UB and more intense and dysfunctional grief symptomatology. Strikingly, unresolved conflict, a major dimension of UB, accounted for nearly 40% of the unique variance in problematic grief, which bore no relation to time since the loss.

Anticipatory Mourning and Narrative Meaning-Making in the Younger Breast Cancer Experience: An Application of the Meaning of Loss Codebook

Breast cancer (BC) in women under 50 is a potentially traumatic experience that can upset a woman’s life during a crucial phase of her lifespan. Anticipatory mourning linked to the diagnosis of BC can produce a series of inevitable losses similar to those of the bereaved. Narration can be one tool to construct meaning, to grow through the experience, and reconfigure time perspectives during and after the illness. The aim of this study was to apply the Meaning of Loss Codebook (MLC) to the narrative context of young women with BC. An ad hoc narrative interview was administered to 17 women at four times during the first year of treatment. A thematic analysis was performed using the MLC, adopting a bottom-up and top-down methodology. The results highlight the MLC’s usefulness in capturing the experiences of the women, allowing for a greater appreciation of the nuances of the meanings embodied in their narratives. The thematic categories grounded in the MLC cover the whole experience of BC during the first year of treatment, attesting to the possibility of extending the use of the MLC to observe the longitudinal elaboration of the psychic experience of BC in addition to its established validity in the context of bereavement and loss.

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.

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.

Social isolation and the mitigation of coronavirus anxiety: The mediating role of meaning

This study examined core belief violation and meaning making as mechanisms mediating the relationship between adherence to social isolation policies for mitigating coronavirus transmission and reduced coronavirus anxiety (CA). Adherence to social isolation policies (social distancing, sheltering in place, and cessation of long-distance travel), use of nonsocial precautionary measures (handwashing, wearing a mask), core belief violation, meaning made of the COVID pandemic, and CA were assessed in a sample of 408 North Americans. Process analysis revealed that adhering to social isolation policies predicted lower levels of CA and that this effect was largely mediated by conservation of core beliefs (e.g., in predictability, control, and self-agency) and ability to make meaning of the pandemic. In contrast, exclusive reliance on nonsocial protections such as handwashing and mask wearing was associated with high levels of CA. These results suggest that social isolation policies support the integrity of adherents' meaning systems, thereby mitigating distress, which carries useful implications for both policy and psychological intervention.

The Integration of Stressful Life Experiences Scale and the Inventory of Complicated Spiritual Grief: The Italian Validation of Two Instruments for Meaning-Focused Assessments of Bereavement

Background: Bereavement is an inevitable event that can cause pain, discomfort, and negative consequences in daily life. Spirituality and religiosity can help people cope with loss and bereavement. Sometimes, however, the death of a loved one can challenge core religious beliefs and faith, which has been found to be a risk factor for prolonged mourning. Objectives: (1) Determine whether the Italian versions of the Integration of Stressful Life Experiences Scale (ISLES) and Inventory of Complicated Spiritual Grief (ICSG) are valid in translation; (2) Evaluate the impact of socio-demographic variables on ISLES and ICSG dimensions; (3) Test whether Complicated Spiritual Grief mediates the relation between meaning reconstruction after loss and integration of the loss experience; (4) Test whether the representation of death as a form of passage or annihilation further moderated the relation between Complicated Spiritual Grief and integration of the loss. Methods: The sample is composed of 348 participants who had lost a loved person in the prior two years. Results: The ISLES and ICSG were validated in Italian and are more appropriately interpreted as having a unifactorial structure. A greater spiritual crisis was manifested in participants with less education, who did not actively participate in religious life, and who had lost a friend rather than a close relative. As hypothesised, spiritual struggle in grief mediated the role of continuing bonds, Emptiness and Meaninglessness, and Sense of Peace in predicting integration of the loss. Furthermore, death representation moderated the impact of spiritual grief on loss, such that those participants who viewed death as a form of annihilation rather than passage reported greater integration of the loss. Conclusion: The role of meaning making in integrating significant loss is partly accounted for by spiritual struggle in a way that can be analysed in Italian contexts through the use of these newly validated instruments.

Examining bereavement-related needs and outcomes among survivors of sudden loss: A latent profile analysis

OBJECTIVE

Recognizing important bereavement-related needs among sudden loss survivors (e.g., suicide, overdose)-a population that is burgeoning and at risk for deleterious outcomes-is a critical task as needs may reflect modifiable grief-related variables that can assist with post-loss adjustment.

METHODS

Latent profile analysis was used among 347 sudden loss survivors to (a) identify distinct patterns of needs among survivors of sudden loss, (b) assess predictors of such profiles, and (c) investigate differences in profiles in terms of bereavement outcomes.

RESULTS

Four classes of bereavement-related needs were identified: a low needs class, a moderate needs-spiritual class, a moderate needs-relational class, and a high needs (HN) class. Clear differences emerged between need classes with the HN class evidencing the greatest level of grief and mental health sequelae.

CONCLUSION

Tending to bereavement-related needs is critical, as they indicate the degree of distress and reflect modifiable therapeutic variables.

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.

Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief

This study examined the relationship between reactions of the bereaved to conditions of the pandemic and severity of their grief and levels of impairment. A total of 831 American adults who lost a loved one to COVID-19 responded to validated measures of dysfunctional grief and functional impairment, as well as items assessing unique complications associated with the pandemic (e.g. resentment toward doctors, social isolation). In combination, circumstantial risk factors accounted for 59% of the variance in social impairment and fully 71% of the variance in pandemic grief, leading to the development of an inventory of Pandemic Grief Risk Factors (PGRF), which displayed a unified factor structure, high reliability and strong convergent validity. Implications for psychological screening and intervention for those bereaved by COVID-19 are briefly noted.

The Utility of the Pandemic Grief Scale in Identifying Functional Impairment from COVID-19 Bereavement

Background: Meeting the needs of people bereaved by COVID-19 poses a substantial challenge to palliative care. The Pandemic Grief Scale (PGS) is a 5-item mental health screener to identify probable cases of dysfunctional grief during the pandemic. Objective: The PGS has strong psychometric and diagnostic features. The objective was to examine the incremental validity of the PGS in identifying mourners at risk of harmful outcomes. Design: A cross-sectional survey design involving sociodemographic questions and self-report measures of pandemic grief, generalized anxiety, depression, post-traumatic stress, separation distress, functional impairment, meaning-making difficulties, and substance use coping. Setting/Subjects: A sample of people bereaved through COVID-19 (N = 1065) in the United States. Results: Fully 56.6% of participants scored above the cut score of ≥7 on the PGS for clinically dysfunctional pandemic grief and 69.7% coped with their loss using drugs or alcohol for at least several days in past two weeks. PGS scores were not associated with time since loss. Hierarchical multiple regression models demonstrated that the PGS uniquely explained variance in functional impairment, meaning-making difficulties, and substance use coping, over relevant background factors, bereavement-related psychopathology, and separation distress. In the final model, the standardized regression coefficients for the PGS were 2-15 times larger than for the other competing measures in explaining each of the three outcomes. Conclusions: The findings underscore the clinical utility of this short and easy-to-use measure in identifying risk of deleterious outcomes across a range of functional and behavioral domains.

Psychological Risk Factors of Functional Impairment After COVID-19 Deaths

CONTEXT

People bereaved from COVID-19 report higher levels of grief than people bereaved from natural causes. The full impact of this onslaught of grief will not be known for some time. Ensuring high-quality bereavement care in the context of COVID-19 presents unprecedented challenges to end-of-life care.

OBJECTIVES

We aimed to determine how psychological symptoms explain functional impairment.

METHODS

A sample of people bereaved through COVID-19 (N = 307) in the United States completed demographic questions and self-report measures of neuroticism; symptoms of depression, generalized anxiety, posttraumatic stress, separation distress, and dysfunctional grief; and functional impairment due to a COVID-19 loss.

RESULTS

Most participants' scores were in the clinical ranges for generalized anxiety, depression, dysfunctional grief, and functional impairment. Functional impairment scores were not associated with age, gender, and time since loss but were associated with being diagnosed with COVID-19, having received professional help with the loss, and a close relationship to the deceased. A logistic regression model showed that, after controlling for covariates, the odds of functional impairment significantly increased by 27% for higher scores in separation distress, 25% for higher scores in dysfunctional grief, and 13% for higher scores in posttraumatic stress.

CONCLUSION

People bereaved because of COVID-19 are at risk of functional impairment, especially if they have symptoms of separation distress, dysfunctional grief, and/or posttraumatic stress. Attention to identifying and treating functional impairment may be important in facilitating grieving persons' full participation in social and economic life during and after the pandemic.

Pandemic Grief Scale: A screening tool for dysfunctional grief due to a COVID-19 loss

Millions of people are grieving the loss of someone who died of COVID-19. However, there have been no screening tools developed to identify individuals who may be suffering from dysfunctional grief during the pandemic. Therefore, the objective of this study was to develop and evaluate the properties of the Pandemic Grief Scale (PGS), which is a brief mental health screener to identify probable cases of dysfunctional grief associated with a COVID-19 death. This 5-item scale, which was based on 831 adults who lost someone to COVID-19, demonstrated solid reliability (αs = 0.86), factorial validity (PCA and CFA support), and construct validity with strong correlations with suicidal ideation and substance use coping. The PGS measures COVID-19 grief equivalently across demographic groups, and discriminates well between persons with and without dysfunctional grief using an optimized cut score of ≥ 7 (87% sensitivity and 71% specificity). An alarming 66% of the sample scored in the clinical range. The PGS also demonstrates incremental validity by explaining 18% additional variance in functional impairment due to a COVID-19 loss beyond measures of depression and generalized anxiety. These results support the PGS as an efficient and valid screening tool for clinical research and practice during a pandemic.

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.

"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.

The Coping Assessment for Bereavement and Loss Experiences (CABLE): Development and initial validation

The authors present the development and validation of the Coping Assessment for Bereavement and Loss Experiences (CABLE), the first instrument designed to assess a range of potentially constructive strategies for coping with grief following the death of a loved one. Exploratory and confirmatory factor analysis with an international sample of bereaved adults (N = 844) yielded a six-factor, 28-item structure. Use of this validated, clinically useful, self-report tool can inform clinicians and researchers in evaluating bereavement coping, and in developing interventions designed to increase the number and broaden the types of coping strategies used to facilitate healing following loss.

Inventory of Complicated Spiritual Grief 2.0 (ICSG 2.0): Validation of a revised measure of spiritual distress in bereavement

Spirituality has long served as a source of solace for many grievers following a loss. For other mourners, whose bereavement experience has been significantly challenged by struggles in their relationship with God and/or their faith community, the opposite is true. Complicated spiritual grief (CSG) is a spiritual crisis following the loss of a loved one. To assess CSG in samples of bereaved adults, a simple-to-use, multidimensional measure of spiritual crisis following loss called the Inventory of Complicated Spiritual Grief (ICSG) was previously developed and validated. However, subsequent research providing greater clarity about the construct of CSG supported the need to revise and update the ICSG. The goal of the present study was to establish the psychometric validity of a revised measure of CSG, called the Inventory of Complicated Spiritual Grief 2.0 (ICSG 2.0), with a large, diverse cohort of bereaved Christian adults (N = 440). Analyses of the bifurcated sample supported a three-factor model measuring insecurity with God, estrangement from the spiritual community, and disruption in religious practices. Further analyses supported the convergent and incremental validity of a 28-item scale relative to other theoretically similar instruments and measures of poor bereavement outcome, indicating the instrument's research and clinical usefulness.

Designing in-depth semi-structured interviews for revealing meaning reconstruction after loss

The recent upsurge in the use of qualitative empirical studies, aiming to provide a deeper understanding of human reactions to loss, requires a methodological account of how to conduct better qualitative research with regard to data collection. This paper offers six general interview guidelines aimed at assisting researchers to achieve quality interviews in qualitative bereavement studies, based on the theoretical framework of meaning (re)construction in loss.

Alcohol use and coping in a cross-sectional study of African American homicide survivors

The loss of a loved one to homicide is associated with considerable distress, often in the form of posttraumatic stress disorder (PTSD) and complicated grief (CG), and alcohol misuse. Yet alcohol-related problems and loss from a homicide are issues that disproportionally affect African Americans. The present study investigated alcohol use in a sample of 54 African American homicide survivors. Although there was a low prevalence of hazardous drinking, alcohol use was associated with higher levels of PTSD, complicated grief, and depression severity. In addition, scores on the Alcohol Use Disorders Identification Test (AUDIT) were correlated with active emotional coping and avoidant emotional coping. In analyses of PTSD symptom clusters, emotional numbing and hyperarousal symptoms were significantly correlated with AUDIT total score.

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

OBJECTIVE

To determine the preliminary feasibility, acceptability, and effects of Meaning-Centered Grief Therapy (MCGT) for parents who lost a child to cancer.

METHOD

Parents who lost a child to cancer and who were between six months and six years after loss and reporting elevated levels of prolonged grief were enrolled in open trials of MCGT, a manualized, one-on-one cognitive-behavioral-existential intervention that used psychoeducation, experiential exercises, and structured discussion to explore themes related to meaning, identity, purpose, and legacy. Parents completed 16 weekly sessions, 60-90 minutes in length, either in person or through videoconferencing. Parents were administered measures of prolonged grief disorder symptoms, meaning in life, and other assessments of psychological adjustment preintervention, mid-intervention, postintervention, and at three months postintervention. Descriptive data from both the in-person and videoconferencing open trial were pooled.ResultEight of 11 (72%) enrolled parents started the MCGT intervention, and six of eight (75%) participants completed all 16 sessions. Participants provided positive feedback about MCGT. Results showed postintervention longitudinal improvements in prolonged grief (d = 1.70), sense of meaning (d = 2.11), depression (d = 0.84), hopelessness (d = 1.01), continuing bonds with their child (d = 1.26), posttraumatic growth (ds = 0.29-1.33), positive affect (d = 0.99), and various health-related quality of life domains (d = 0.46-0.71). Most treatment gains were either maintained or increased at the three-month follow-up assessment.Significance of resultsOverall, preliminary data suggest that this 16-session, manualized cognitive-behavioral-existential intervention is feasible, acceptable, and associated with transdiagnostic improvements in psychological functioning among parents who have lost a child to cancer. Future research should examine MCGT with a larger sample in a randomized controlled trial.

Investigating risk for grief severity: Attachment to the deceased and relationship quality

Previous research examining the interrelationship between attachment, relationship quality, and bereavement outcomes suffers from a lack of precision and sophistication in the measurement of the core constructs of interest. The present study adapted an existing measure of attachment and employed a novel instrument of relationship quality to examine specific attachment to and relationship quality with the deceased as contributors to grief symptom severity. A sample of 385 bereaved college students completed measures retrospectively assessing relationship quality, attachment to the deceased, and grief symptomatology. Findings indicate that specific attachment to the deceased differs significantly from global attachment style and that relationship quality and attachment anxiety and avoidance interact in significant ways to predict the risk of grief severity. Specifically, individuals with a Preoccupied attachment style (high anxiety, low avoidance) are most at risk for adverse grief reactions in the context of high relationship closeness and conflict. This study is limited by an over-representation of extended family loss, which may have unique implications for attachment and relationship quality. Grief therapists should consider the implications of attachment and relationship quality with the deceased in the selection of relationship-enhancing or relational problem-solving interventions.

Meaning reconstruction in bereavement: Development of a research program

The death of a significant person, especially when it comes tragically or prematurely, can shake the foundations of our assumptive and relational world and lead to anguished attempts to find meaning in the loss and in our lives in its aftermath. In this article, I review one program of research focused on this attempt at meaning reconstruction, describe recently developed measures of meaning in mourning, and discuss several therapeutic techniques for helping clients make sense of the death and rework their attachment relationship to the deceased. I conclude by illustrating some of this work in my therapy with a couple grieving the loss of not one but two children to tragic accidents, as they try to adapt to a compound traumatic bereavement.

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.

Distinguishing the meaning making processes of survivors of suicide loss: An expansion of the meaning of loss codebook

Suicide loss represents particularly a difficult form of bereavement due to the challenges that volitional death poses to survivors. Understanding these challenges requires recognition of the idiosyncratic processes of meaning reconstruction for this specific group of grievers. The current study investigates such processes in survivors of suicide loss (SOSL) by utilizing the Meaning of Loss Codebook (MLC) to analyze the narratives of eight SOSL. The findings contribute to a broader understanding of meaning making following suicide, strengthen the validity of the MLC by demonstrating its appropriateness for SOSL, and illuminate unique challenges faced by SOSL, resulting in the proposal of supplemental MLC codes. Research and clinical implications are discussed.

Prolonged grief symptomatology following violent loss: the mediating role of meaning

Background: Prolonged Grief Disorder (PGD) is over-represented among those who have lost loved ones to violent causes. To tailor PGD interventions for this vulnerable population it is critical to examine the aetiology of PGD specifically in the context of violent death bereavement. Previous studies have suggested that violent loss increases symptoms of PGD by hindering the mourner's ability to make meaning of the death or its aftermath. However, these studies have relied on cross sectional data that preclude genuine prediction and have not differentiated among specific themes of meaning. Objective: This study aimed to identify specific themes of meaning that mediate the detrimental impact of violent loss on subsequent emergence of PGD symptomatology among the violently bereft. Method: A longitudinal, prospective design (N = 171) was used to assess violent loss and themes of meaning an average of six months post-loss allowing for prediction of PGD symptoms an average of eight months later. Results: Violent loss had a significant indirect effect on PGD symptomatology when meaning themes focusing on sense of peace and continuing bonds served as mediators. Conclusions: This study demonstrates the mediating role that specific meaning themes play in the development of PGD symptomatology following violent loss. These findings highlight the potential benefits of applying a meaning-based intervention approach with the violently bereft.

The Social Meaning in Life Events Scale (SMILES): A preliminary psychometric evaluation in a bereaved sample

A mourner's success in making meaning of a loss has proven key in predicting a wide array of bereavement outcomes. However, much of this meaning-making process takes place in an interpersonal framework that is hypothesized to either aid or obstruct this process. To date, a psychometrically validated measure of the degree to which a mourner successfully makes meaning of a loss in a social context has yet to be developed. The present study examines the factor structure, reliability, and validity of a new measure called the Social Meaning in Life Events Scale (SMILES) in a sample of bereaved college students (N = 590). The SMILES displayed a two-factor structure, with one factor assessing the extent to which a mourner's efforts at making meaning were invalidated (Social Invalidation subscale), and the other assessing the extent to which a mourner's meaning-making process was validated (Social Validation subscale). The subscales displayed good reliability and construct validity in reference to several outcome variables of interest (complicated grief, general health, and post-loss growth), as well as related but different variables (social support and meaning made). The subscales also demonstrated group differences according to two demographic variables associated with complications in the mourning process (age and mode of loss), as well as incremental validity in predicting adverse bereavement outcomes over and above general social support. Clinical and research implications involving the use of this new measure are discussed.

Performative retelling: Healing community stories of loss through Playback Theatre

Restorative retelling (RR) is an evidence-based procedure for facilitating adaptation following traumatic bereavement. In this paper, we introduce performative retelling (PR), a variation on RR, which fosters healing from personal losses and portrays personal reactions to collective tragedy. We describe our collaboration with an ex-offender reentry program, the Memphis Police Department, and Playback Theatre to use improvisational community theatre to bridge the gap between law enforcement and the citizens they serve. We review program outcomes to-date and illustrate its impact using participant stories. We argue that training police and citizens in PR can potentially transform broken narratives of police-community relations.

A novel Family Dignity Intervention (FDI) for enhancing and informing holistic palliative care in Asia: study protocol for a randomized controlled trial

Background

The lack of a holistic approach to palliative care can lead to a fractured sense of dignity at the end of life, resulting in depression, hopelessness, feelings of being a burden to others, and the loss of the will to live among terminally ill patients. Building on the clinical foundation of Dignity Therapy, together with the empirical understanding of dignity-related concerns of Asian families facing terminal illness, a novel Family Dignity Intervention (FDI) has been developed for Asian palliative care. FDI comprises a recorded interview with a patient and their primary family caregiver, which is transcribed, edited into a legacy document, and returned to the dyads for sharing with the rest of the patient’s family. The aims of this study are to assess the feasibility, acceptability and potential effectiveness of FDI in reducing psychosocial, emotional, spiritual, and psychophysiological distress in community-dwelling and in-patient, Asian, older terminally ill patients and their families living in Singapore.

Methods/design

An open-label randomized controlled trial. One hundred and twenty-six patient-family dyads are randomly allocated to one of two groups: (1) an intervention group (FDI offered in addition to standard psychological care) and (2) a control group (standard psychological care). Both quantitative and qualitative outcomes are assessed in face-to-face interviews at baseline, 3 days and 2 weeks after intervention, as well as during an exit interview with family caregivers at 2 months post bereavement. Primary outcome measures include sense of dignity for patients and psychological distress for caregivers. Secondary outcomes include meaning in life, quality of life, spirituality, hopefulness, perceived support, and psychophysiological wellbeing, as well as bereavement outcomes for caregivers. Qualitative data are analyzed using the Framework method.

Discussion

To date, there is no available palliative care intervention for dignity enhancement in Asia. This first-of-its-kind study develops and tests an evidence-based, family driven, psycho-socio-spiritual intervention for enhancing dignity and wellbeing among Asian patients and families facing mortality. It addresses a critical gap in the provision of holistic palliative care. The expected outcomes will contribute to advancements in both theories and practices of palliative care for Singapore and its neighboring regions while serving to inform similar developments in other Asian communities.

Trial registration

ClinicalTrials.gov, ID: NCT03200730. Registered on 26 June 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2325-5) contains supplementary material, which is available to authorized users.

Recommendations for research on suicide loss: A commentary

As detailed in the lead article in this Special Issue, the Survivors of Suicide Loss Task Force of the National Action Alliance for Suicide Prevention in the United States has recently worked to formulate national guidelines to mitigate the harmful aftereffects of suicide in social and family systems. In the present article, we elaborate on one of four strategic directions addressed by the Task Force, namely, the development of goals and objectives for surveillance, research and evaluation of the impact of suicide loss. By emphasizing methodological guidelines for the conduct of future studies and illustrating progressive programs of investigation as leading exemplars, we hope to contribute to the sophistication of research on public health initiatives, peer support and professional intervention with communities, families and individuals affected by suicide loss.

Mental Health Symptomatology and Exposure to Non-Fatal Suicidal Behavior: Factors That Predict Vulnerability and Resilience Among College Students

Despite efforts to identify risk factors following exposure to completed suicide, research has paid less attention to the associations between exposure to non-fatal suicide behavior (NFSB) and mental health symptomatology-factors that may underlie one's susceptibility to future suicidal thoughts and behaviors. This study examined differences in mental health symptomatology among 192 college students exposed to NFSB and 202 exposed to general stressors. Results indicated that students exposed to NFSB had significantly higher levels of depression and anxiety compared to those exposed to a variety of other stressors but not NFSB. Furthermore, among those exposed, a number of risk and protective factors emerged in relation to psychological sequelae, such as emotional stability, social support, and the quality of the relationship between the exposed and suicidal individual. These findings highlight the importance of enhancing provisions of support for those exposed to NFSB.