Grief Therapy and the Reconstruction of Meaning: From Principles to Practice

Specificity and integration of meaning in self-defining memories of breast cancer survivors: clinical reflections to promote a narrative identity integration

Potential traumatic events, such as breast cancer, can influence autobiographical memory (AM), interrupting the continuity of narrative identity. AM is based on a hierarchical search across different levels of specificity that are indexed from top to bottom when a memory is retrieved. In the breast cancer field, non-specific AMs are an observed clinical phenomenon. In particular, breast cancer survivors report issues related to self-defining memories (SDMs), specific and significant AMs that evoke strong emotions and sensory details at the time of memory. SDMs are linked to life goals and facilitate adaptation to critical experiences, preserving the continuity of identity. This study explored the narrative identity integration process of breast cancer survivors, analyzing themes, specificity, and integrative meaning in SDMs. Ten women participated in an online group support program centered on the integration of AMs linked to the cancer journey. Participants were asked to assess their body image perceptions, filling out an online survey three times, in which they had to report three SDMs each time. A reflexive thematic analysis of the SDMs identified three main themes: the onset of breast cancer; the labeling of negative emotions, and changes in the body. The results indicated inhibited retrieval of specific episodes, fostering a progressive failure in memory characterization and the concurrent meaning-making process. Participants struggled with connecting the memories to insights regarding their self and life, as well as relating the memories to external conditions and other individuals. Further studies might examine the impact of these difficulties on the psychological adjustment of BC long-term survivors. They could also explore cognitive reconstruction by reframing the memories and re-evaluating their traumatic meanings.

Letter Writing as a Clinical Tool in Grief Psychotherapy

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

Prenatal twin-less twins: The congenital loss experience of individuals who lost a twin sibling in utero

Congenital loss involves the loss of an immediate family member, specifically a parent or sibling, either during or prior to birth, and bears unique bereavement-related challenges. The current study investigated the unique congenital loss experiences of those who lost a twin sibling in utero. Through analysis of interviews with 18 Jewish Israeli participants who encountered this type of twin loss, a more comprehensive understanding of their experiences was attempted. The research employed a hybrid methodology, combining two qualitative thematic analysis methods: deductive and data-driven inductive approaches. The analysis revealed four themes: incoherency and uncertainty, ownership over a limited story, continuing an unborn bond, and the identity of a "twin-less" twin. The findings underscore the unique nature of twin loss in utero.

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

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

A quasi-experimental trial of narrative reconstruction for prolonged grief disorder: Symptomatic improvement and enhanced memory integration

BACKGROUND

Prolonged grief disorder (PGD) was recently approved as a formal diagnosis in the DSM-5-TR. The implementation of bereavement interventions is frequently requested, but their effectiveness has been controversial. Narrative reconstruction (NR) is a time-limited integrative therapy, originally developed for the treatment of post-traumatic stress disorder (PTSD) and adapted for the treatment of PGD. NR consists of exposure to the loss memory, a detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved.

OBJECTIVES

In this study we evaluated the efficacy of NR for PGD.

METHOD

In this study, 33 participants with PGD were quasi-randomized-that is, assigned to an immediate (n = 20) or delayed (n = 13) 16-session NR intervention. PGD, intrusion, avoidance and depression symptoms, as well as levels of the loss memory integration, were assessed at pretreatment, post-treatment, and at a 3-month follow-up.

RESULTS

Mixed linear models showed significant intervention effects for PGD and intrusive symptomatology. Results also showed an increase in integration of the loss memory, and improvements remained stable for all outcomes at follow-up.

CONCLUSION

In this study we established NR as an effective intervention for PGD and call for further validation in future studies. Integrating this intervention into the routine care of people with PGD seems important and beneficial.

Ambivalence Resolution in Meaning Reconstruction Grief Therapy: An Exploratory Study

In psychotherapy, ambivalence may be conceptualized as a conflict between two distinct motivations: one that is favorable to change (pro-change) and another that favors the maintenance of a problematic pattern (pro status quo). Previous studies identified two processes by which clients resolve this conflict: imposing the innovative part and silencing the problematic one (dominance), and establishing negotiations between the innovative and the pro status quo parts (negotiation). The present exploratory study examined ambivalence resolution in a sample of clients diagnosed with complicated grief. Results revealed that, in recovered cases, negotiation increases and dominance decreases from the beginning until the middle sessions of therapy and the opposite tendency is observed from the middle to the final sessions. Unchanged cases reveal an overall high proportion of dominance and an overall low proportion of negotiation. These results are partially divergent from those reported in previous studies with samples of clients diagnosed with major depression.

The bereavement experiences of families of potential organ donors: a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES

To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature.

METHOD

Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death.

FINDINGS

Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient's death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement.

RECOMMENDATIONS

Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs.

CONCLUSION

The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow.

A thematic analysis of bereaved adults' meaning-making experience of loss through playing video games

Introduction

Recalling personal memories on the loss and deriving new meanings from them is deemed necessary for adapting to bereavement. Recent studies suggest that games can afford players meaningful experiences that can support players through stressful life events, but its potential on the meaning-making of loss has not been much explored. To address this gap, we investigated the bereaved players' experiences of playing commercial video games that elicited their personal memories of loss and what meanings they derived from those experiences.

Method

Twelve adult players with bereavement experiences (six male, six female, age range: 20-31) played two video games (Bear's Restaurant and Spiritfarer). Their experiences during and after gameplay were tracked via play diaries and in-depth interviews. Data was analyzed using thematic analysis method.

Results

We discovered seven themes on the meanings that players made from their gameplay experience: "Recalling memories", "Avoiding engagement with the pain", "Recognizing positive emotions", "Acknowledging the deceased's perspective", "Reviewing the meaning of loss", "Planning a better future", and "Fulfilling a wish". Our findings indicate that bereaved players recalled and related their autobiographical memories to their in-game experiences. Furthermore, they derived new meanings on both the loss and their post-loss life after playing video games.

Discussion

We discuss how video games can provide a unique meaning-making experience to bereaved players by affording them an agency to actively reconstruct their narrative of loss and facilitating the sharing of grief.

Caregiver-child communication on parental loss in the context of the AIDS epidemic in Namibia

Personal grief takes place in a social context, such as the family setting. This study aimed to understand how Namibian caregivers and children/adolescents communicate parental loss, in the context of the HIV/AIDS epidemic. An ethnographic design was used, in which 38 children, adolescents, and their caregivers were interviewed. The results show that caregivers shared few memories and provided minimal information about the deceased parents. However, the majority of adolescents and children wished for information. A relational Sender-Message-Channel-Receiver model was used to map the reasons for this silence. This model is useful for grief interventions that aim to strengthen communication.

"The Health Caregivers Did Not Care about Me after the Loss": Maternal Experiences of Perinatal Loss in the Kumasi Metropolitan Area, Ghana

One of the common undesirable outcomes of pregnancy is perinatal loss. Healthcare systems strive to reduce the incidence of perinatal loss but typically little attention is on the experiences of bereaved mothers following perinatal loss, particularly in low and middle-income countries where such deaths are common. This research explored the lived experiences of mothers with perinatal loss in the Kumasi metropolis, Ghana. A qualitative design was used to explore the experiences of nine (9) bereaved mothers from the Komfo Anokye Teaching Hospital's postnatal ward and the Mother and Baby Unit. Data were collected through face-to-face interviews using a semi-structured interview guide, audio-recorded, and thematically analyzed. One major finding was that mothers restricted mourning their dead babies based on fear of recurrent perinatal loss and traditional beliefs on delayed return to fertility. Mothers blamed healthcare providers for their loss due to their concerns about care received. Gaps in communication flow from healthcare professionals to bereaved mothers were commonly identified as mothers struggled to make meaning of their loss and coped with cultural restrictions and beliefs. Healthcare professionals must explore mothers' concerns and "gut-feelings," and pay attention to their communication needs following perinatal loss.

Meaning-making following loss among bereaved spouses during the COVID-19 pandemic (the CO-LIVE study)

This study investigates how individuals construe, understand, and make sense of experiences during the first wave of the COVID-19 pandemic. Seventeen semi-structured interviews were conducted with bereaved spouses focusing on meaning attribution to the death of their partner. The interviewees were lacking adequate information, personalized care, and physical or emotional proximity; these challenges complicated their experience of a meaningful death of their partner. Concomitantly, many interviewees appreciated the exchange of experiences with others and any last moments together with their partner. Bereaved spouses actively sought valuable moments, during and after bereavement, that contributed to the perceived meaning.

Bereavement Support Services in a National Sample of Hospices: A Content Analysis

Although the Medicare Hospice Benefit mandates that hospices offer bereavement support services to families for at least 1 year following the death of a patient, it does not stipulate which services they should offer. As a result, little is known about what bereavement support services hospices provide, especially on a national scale. The current study recruited a national sample of hospice representatives who responded to an open-ended question that asked, "What types of bereavement support services does your hospice provide to families?" Seventy-six viable responses were recorded and content analyzed. Four overarching domains emerged: (a) timing of support, (b) providers of support, (c) targets of support, and (d) formats of support. Other notable findings included the underutilization of bereavement support services and the utility of informal support formats. These findings present implications for future study regarding which specific aspects of hospice bereavement support services are most beneficial to bereaved families.

Exploring the impact of healthcare workers communication with women who have experienced stillbirth in Malawi, Tanzania and Zambia. A grounded theory study

BACKGROUND

Communication and interaction with healthcare workers at the time of stillbirth remain in parents' long-term memories and impact on emotional and psychological well-being. Cultural attitudes and norms influence how stillbirth is acknowledged and discussed in society. There is limited evidence on how women from sub-Saharan Africa became aware of the death of their babies. This research explored how women perceived the approach adopted by healthcare workers when the news of their stillbirth was disclosed to them.

METHODS

Grounded theory study. Women (n = 33) who had birthed a stillborn baby in the preceding 12 months were purposively sampled and participated in in-depth interviews (9 in Zambia, 16 in Tanzania and 8 in Malawi). Informed consent was gained from all participants. Data were analysed via a coding process using constant comparative analysis.

FINDINGS

Women sacrificed individualized and personal grieving strategies to conform and behave according to what was expected within their community. An overarching theme of cultural conformity overrides personal grief incorporated four sub-themes: perceiving something was wrong, the unexpected outcome, experience contrasting emotions, bonding with the baby.

DISCUSSION AND CONCLUSIONS

Most participants embarked on a negative 'emotion work' to adapt and suppress emotions and grief due to cultural expectations. Inability to voice the trauma of losing a baby may lead to perinatal mental health issues and needs addressing. Maternity healthcare workers should encourage women to express their feelings and grief. Appropriate training in perinatal bereavement care including good communication, appropriate attitudes and provision of meaningful information to grieving women is recommended.

How I Learned to Stop Worrying and Love the Eco-Apocalypse: An Existential Approach to Accepting Eco-Anxiety

Climate crisis presents a near-term existential threat to the human species, one that society has neither the physical nor psychological infrastructure to manage. Eco-anxiety increases as awareness about climate crisis spreads. Despite an urgent need for resources on how to help people cope with the psychological ramifications of climate crisis, there is little literature that both addresses people's apocalyptic fears and takes the scientific bases of those fears seriously. In this article, I synthesize research on existential psychology, Acceptance and Commitment Therapy, grief, and end-of-life care to present an original perspective on how people, individually and collectively, can become psychologically resilient to climate crisis. First, I establish that death anxiety underlies eco-anxiety. Second, I demonstrate that preparing psychologically for eco-apocalypse requires people to cultivate death acceptance. Finally, I illustrate how commitment to palliative values can enable people to live rich and meaningful lives despite their most likely imminent end.

[Bereavement and its clinical implications, conceptual developments and ways of supporting bereaved families]

Bereavement is a natural process whose scope has long been essentially social and collective before it was increasingly limited to the private sphere. In recent years, the redefinition of the various clinical manifestations of grief raises the question of diagnosis when it becomes a disorder and the question of whether or not adapted treatments are necessary in certain situations. We will place the bereavement process in a cultural and social perspective, before focusing on the centrality of rituals as a modality of support and resilience.

Growing in Suffering: The Curvilinear Relationship Between Prolonged Grief and Post-traumatic Growth of Recently Bereaved Individual During the COVID-19 Pandemic

The outbreak of the COVID-19 pandemic brought new challenges to mourning and growth of bereaved. The purpose is to explore the relationship between the prolonged grief (PG) symptoms and the post-traumatic growth (PTG) of recently bereaved people during the COVID-19 period, and the mediating role of meaning making. 305 participants were recruited to complete the Posttraumatic Growth Inventory, Inventory of Complicated Grief, and Integration of Stressful Life Experiences Scale. Hierarchical multiple regression analyses and Medcurve in SPSS were adapted to test the hypotheses. The results revealed that there was a curvilinear relationship between PG and PTG and meaning making had a completely mediating effect on this relationship. Different intervention goals - whether alleviating distress or cultivating growth - should be set up according to the level of grief for recently bereaved individuals during COVID-19. More attention should be paid to the role of meaning making in the future clinical practice.

À l’ère de l’euthanasie : la clinique du deuil en contexte de mort anticipée

Les soignants en oncologie et en soins palliatifs gagnent à considérer les effets de l’euthanasie sur leur pratique. Choisir les circonstances de sa mort est dans l’ère du temps, ce qui influence les trajectoires de soins. Ainsi, il devient pertinent de s’intéresser à l’impact du décès anticipé (euthanasique ou naturel) à la fois sur l’accompagnement du patient et sur celui des proches endeuillés. À cet égard, nous proposons une approche relationnelle et des pistes d’intervention fondées sur les empreintes laissées par la mort et le paysage relationnel du deuil.

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.

Partner bereavement when parenting dependent children: What factors influence adjustment?

Little is known about those who are widowed while raising dependent children. This study aimed to explore the factors which influence adjustment to partner death. Seven fathers and five mothers were interviewed, and constructivist grounded theory was used. Three interrelated themes were identified: Interpersonal influences, Intrapersonal influences, and Contextual influences. Dependent children meant sole responsibility and increased demands, yet ultimately provided widowed parents a purpose. Participants highlighted the need for increased awareness of young widowhood at a systemic and cultural level, to improve communication around death and young widowhood. Implications included social, financial and therapeutic interventions.

Expressing grief through metaphors: family caregivers' experience of care and grief during the Covid-19 pandemic

Purpose: The COVID-19 pandemic has disrupted thousands of individuals’ experience of caregiving and grief. This qualitative study aimed to gain in-dept understanding of family caregivers’ lived experiences of caregiving and bereavement in the context of the COVID-19 pandemic in Quebec, Canada. The study also aimed at providing new insight about caregiving and bereavement by analysing the metaphors family caregivers use to report their experiences. Methods: The design of this study was guided by an interpretative phenomenological approach. In-depth interviews were conducted with twenty bereaved family caregivers who had lost a loved one during the first waves of the pandemic. Results: Results indicate that bereaved family caregivers lived and understood their experience in terms of metaphoric cut-offs, obstructions and shockwaves. These three metaphors represented the grief process and the bereaved’s quest for social connection, narrative coherence and recognition. Conclusion: By identifying the meaning of the bereaved’s metaphors and the quest they reveal, our study underlines the singularity of pandemic grief and points to the value and meaning of caregiving with regard to the grieving process.

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.

Emotional processing during the therapy for complicated grief

OBJECTIVE

Prior research, mainly conducted on depression, observed that clients' improved capability to process their emotions predicted better therapeutic outcomes. The current comparative study aimed to investigate whether emotional processing was related to therapeutic change in complicated grief.

METHOD

We analyzed two contrasting cases (good or poor outcome) treated with grief constructivist therapy. In both cases we investigated the association of emotional processing (Experiencing Scale) to (1) therapeutic outcome (Inventory of Complicated Grief), and (2) change in the type of grief-related emotions (Emotions Episodes).

RESULTS

The session-by-session growth of clients' emotional processing and the change of grief-related emotions were qualitatively explored throughout both cases. Compared with the poor outcome case, the good outcome case achieved more improvement in the ability to process emotions. Such improvement occurred alongside a deeper change in the type of grief-related emotions aroused, from maladaptive to more adaptive responses.

CONCLUSION

Our findings suggest that a higher emotional processing capability may be associated with the transformation of grief-related maladaptive emotions and with the improvement of complicated grief condition.

Embodied meaning making: Memorial tattoos as a visual expression of grief

Memorial tattoos are an increasingly prevalent response to the death of a loved one. This study explored the role of memorial tattoos as an active response to loss and a visual expression of grief. Twenty-two people with memorial tattoos volunteered to be interviewed and to have photographs taken of their tattoos. Through a grounded theory analysis, the core category emerged that memorial tattoos were an expression of embodied meaning making in the grief experience. Under this core category, the themes of creating permanence, constructing control, and symbolizing the bond further elucidated the meaning making process represented in memorial tattoos.

Psychological Interventions for Individuals Bereaved by Homicide: A Systematic Review

Research has demonstrated that approximately 45-50% of individuals show healthy levels of psychological and physical functioning in the first 12 months post-loss. Homicidal bereavement (loss due to murder or manslaughter) does not appear to follow this pattern. Homicide-related mental health difficulties are a serious problem worldwide, displaying high rates of lifetime incidence, high chronicity, and role impairment. Individuals are at increased risk to develop symptoms of post-traumatic stress disorder (PTSD), complicated grief (CG), and depression. Nevertheless, a systematic review specifically on the efficacy of psychological interventions following homicidal loss has not yet been conducted. The current systematic review (registered via PROSPERO) aimed to review the psychological interventions available and report their effectiveness. Of 77 records, 7 met predefined inclusion criteria. Studies presented different methodologies, tested different clinical models, and treatment conditions. Thus, a narrative systematic review was conducted. Studies included manualized interventions to deliver 1:1 and group sessions. Cognitive behavioral therapy, restorative retelling, and eye movement desensitization and reprocessing were the main models used together with psychoeducational elements about trauma and grief responses. Overall, symptoms of PTSD, CG, and depression decreased significantly postintervention. Sustained improvements were reported for PTSD and depressive symptoms at the follow-up measurements. Mixed results were found regarding how individual (age, gender) and external factors (time since loss, relationship with the deceased) impact on symptom progression. As a result of differences in methodologies, categorization of therapies, methodological differences, and small sample sizes, important questions remain unanswered. Further randomized controlled trials and expert consensus could be considered.

Posttraumatic Growth in Women who have Experienced Loss of a Child

PURPOSE

The purpose of this study was to describe and explore the experiences of women who have lost a child and the degree of posttraumatic growth revealed by the experiences.

STUDY DESIGN AND METHOD

A qualitative descriptive study was conducted with interviews of mothers and grandmothers of children who died using the posttraumatic growth framework.

FINDINGS

Participants included 11 mothers and 2 grandmothers. The posttraumatic growth framework was useful in examining their experiences. Seven themes were identified through data analysis: When my child died, I lost part of myself; Anticipated loss versus unanticipated loss; Picking up the pieces of my life; Support, kindness, and compassion helped; Moving on while still broken; Never forgotten, always in my heart; and Holding my loved ones close.

CLINICAL IMPLICATIONS

Nurses are in strategic positions to help women who have experienced the loss of a child by building rapport, establishing trust, and demonstrating empathy.

Student veterans and adjustment to college: Making meaning of military experiences

OBJECTIVE

This study examined the relationships among meaning making, military stressor severity, and adjustment to college among student service members/veterans (SSM/Vs).

PARTICIPANTS

Participants were 128 SSM/Vs enrolled in postsecondary education from April to June 2016.

METHODS

Participants completed online self-report rating scales of stressor severity for their most stressful military event, meaning made of that stressor, and adjustment to college.

RESULTS

Regression analyses revealed that made meaning of military stressors was associated with more positive academic, social, and emotional adjustment to college. Stressor severity was not associated with adjustment, nor did made meaning moderate the relationship between stressor severity and adjustment to college.

CONCLUSION

These findings provide preliminary evidence that making meaning of stressful military experiences can promote academic, social, and emotional adjustment to college among SSM/Vs and has implications for incorporating meaning making strategies into university and clinical programs aimed at promoting adjustment to college in this population.

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.

Development and evaluation of the Good Grief program for young people bereaved by familial cancer

BACKGROUND

Adolescents and young adults (AYAs) bereaved by the death of a parent or sibling from cancer report unique psychosocial needs and can have difficulty adjusting to their loss. Unaddressed, this can result in poor long-term bereavement outcomes. This paper describes the development and evaluation of Good Grief - a 3-day camp-based program focused on meeting coping, social support, and respite needs of AYAs bereaved by familial cancer.

METHODS

One hundred and nine Australian AYAs (68% female; age: 12-25 years, M = 16.63) participated in the evaluation. Grief intensity (Texas Revised Inventory of Grief), meaning-making (Grief and Meaning Reconstruction Inventory), trauma coping (Perceived Ability to Cope with Trauma Scale) and unmet needs (Bereaved Cancer Needs Instrument) measures were administered pre-program and 3-months post-program. Acceptability was measured after each session and at the program's conclusion. Appropriateness was measured at 3-month follow-up. Thirteen participants were interviewed three months post-program on their perceptions of the program.

RESULTS

Participants reported high program satisfaction, engagement with psychosocial sessions, and enjoyment of recreational activities. Significant improvements were observed in trauma coping abilities and reductions in unmet needs for managing emotions, social support, respite, future planning, and accessing information and support domains. No change was evident in grief intensity or meaning-making as measured quantitatively. Interviews supported these quantitative findings but also identified evidence of personal growth, a component of meaning-making.

CONCLUSIONS

Good Grief is a highly acceptable and beneficial intervention that addresses the unique needs of AYAs bereaved by familial cancer.

Current Grief Support in Pediatric Palliative Care

Grief support changes as more is learned from current grief theory and research. The authors provide a comprehensive overview of current grief support as it relates to Pediatric Palliative Care (PPC). The following aspects of grief are addressed: (1) anticipatory grief: the nondeath losses that occur with a complex and chronic illness, as well as the time leading up to death; (2) grief around the time of death: the intense and sacred experience of companioning with a dying child; (3) grief after death: supporting bereavement and mourning through programing and other methods; (4) innovative approaches: the future of grief support. The contents of this article are meant to support and educate programs currently providing grief services and those aiming to begin the meaningful work of grief support.

Individual and community psychological experiences of the COVID-19 pandemic: The state of emergency in Portugal

Individuals have different ways of coping with crisis. Individual factors, family and contextual features, and community support may influence how individuals feel, think and act during a crisis. COVID-19 was an unexpected pandemic that forced many European countries to take confinement measures and restrict social face to face interactions. This study is an effort to understand how Portuguese residents dealt with the pandemic during the first confinement period, considering different sociodemographic characteristics and trauma exposure perceptions. Five hundred and five adults, between 18 and 79 years old participated in this study via an online self-report assessment protocol. Sociodemographic characteristics such as gender, age, marital status, employment status, and caring responsibilities had an impact on individuals' perceptions regarding their exposure to the pandemic and their quality of life. Perceived exposure to the pandemic was found to predict quality of life in the physical, psychological, and environmental domains. Results have practical implications for European and local policy-making, as well as for targeting psychological interventions for those whose mental health has been negatively affected by the pandemic and for those who may become more affected if confinement measures are implemented again.

A Phone-Based Early Psychological Intervention for Supporting Bereaved Families in the Time of COVID-19

The exceptional circumstances of the Coronavirus disease (COVID-19) pandemic are making the grief processes challenging for families who are losing a relative for COVID-19. This community case study aimed to describe a phone-based primary preventive psychological intervention that has been delivered to these families by the Clinical Psychology unit of an Italian hospital. In particular, the article reports how the intervention has been organized within the overall hospital care pathway for families, the specific contents and components of the intervention, and the seven-phase structure of the intervention. The unique features and related challenges of the intervention, along with the implications for clinical practice, are discussed.

Strategies to Cope With the COVID-Related Deaths Among Family Members

The extraordinary circumstances of deaths during COVID-19 pandemic have been challenging for the deceased's families. This contribution aims to describe some spontaneous strategies that family members may adopt to cope with the loss of a relative for COVID-19. The present reflection derives from the experience of a clinical psychology unit of one of the biggest public hospital in Milan, Italy, which supported 246 families of COVID-19 victims in the 1st days after the loss. Spontaneous strategies used by family members to deal with such a unique mourning process involved: creating alternative good-bye rituals, normalizing the loss, addressing faith and hope, highlighting the perks of isolation, supporting others in need, and delivering the bad news to others. These observed strategies may suggest how to assess and support a "normal" bereavement process during the extraordinary COVID-19 circumstances, in order to prevent further psychological distress.

In Dialogue: How Writing to the Dead and the Living Can Increase Self-Awareness in Those Bereaved by Addiction

This article examines how writing can increase the self-awareness of a socially isolated and often stigmatized population: those bereaved by addiction. Writing about a traumatic event has been shown to increase self-awareness which can improve health and regulate negative behaviors. Using narrative analysis on the writing of individuals bereaved by addiction, this study found that participants were able to increase their self-awareness through writing to the dead, the living and themselves. Participants’ writing also demonstrated their attempts to make sense and make meaning out of their loss which are both strong predictors of positive health outcomes. All participants in this study demonstrated increased self-awareness as well as sense-making and/or meaning-making which can lead to improvements in behavior regulation, psychological health and physical heath. This suggests that writing may be a uniquely beneficial therapeutic intervention for those experiencing disenfranchised grief as a result of bereavement by addiction.

Correlates of end-of-life treatment preferences among young adults and older adults

The purpose of this study was to investigate correlates of end-of-life treatment preferences. Young adults (n = 117) and older adults (n = 305) completed an interview survey. Compared to older adults, young adults endorsed a desire for more medical intervention in end-of-life scenarios. After controlling for age cohort and education, a desire for more medical intervention in end-of-life scenarios was associated with higher religiosity, greater death anxiety, and more positive attitudes toward aging but not with physical or mental health. End-of-life treatment preferences may be more closely related to attitudes, beliefs, and practices than health status.

Operationalizing intersectionality as a framework in qualitative grief research

The field of thanatology emphasizes understanding grief as situated within social contexts. Yet, existing research largely examines individual experiences, neglecting to critically examine the role that sociocultural systems and forms of oppression play in how people grieve. In this manuscript, we use the social constructionist model of grief as an epistemological stepping stone to operationalize intersectionality as a framework to engage in this critical qualitative research. We provide an overview of the research process implementing an intersectional framework, including examples of research questions and procedures throughout, and discuss implications for helping praxis and education and future scholarship.

Suicidal Thoughts and Behaviors Among Swedish Suicide-Bereaved Women: Increased Risk Associated With the Loss of a Child, Feelings of Guilt and Shame, and Perceived Avoidance From Family Members

Previous studies have shown that suicide-bereaved individuals may suffer increased risk of suicidal thoughts and behaviors (STBs) due to traumatic grief. In this paper, we present the self-reported rate of STB among Swedish suicide-bereaved women (N = 293). Data was collected in a cross-sectional anonymous survey on the homepages of Sweden’s leading suicide survivor organization, SPES. We used logistic regression to evaluate risks (of any STB event) related to losing a child compared to other relatives and the experience of social avoidance from family members, as well as feelings of shame and guilt. The self-reported rate of suicidal thoughts, plans, and attempts was 60, 24, and 5 percent, respectively, considerably higher than in the general population. Results showed that all of the investigated variables were independent risk factors for STB (ORs ranged between 1.29 and 2.69). Women who had both lost a child and experienced family avoidance reported the highest STB rate (87.5%), and we found an interaction effect between these two risk factors (OR = 3.45; 95% CI = 1.05–11.32) that was related to self-reported shame. It is concluded that perceived responsibility for someone else’s suicide, and the social avoidance associated with it, may play an important role for suicide survivors and should be targeted by postvention activities.

"It Made Me More Human": Existential Journeys of Family Caregivers from Prognosis Notification Until after the Death of a Loved One

Background: An essential component of palliative care (PC) is providing psychological and existential support to the family caregivers. However, there is scant research on the existential journeys of family caregivers throughout the disease trajectory and beyond. Objective: This study aimed to obtain a deep understanding of the existential journeys of family caregivers from prognosis notification until after the death. Setting/Participants: A purposive sample of 22 caregivers of terminally ill family members who had died was recruited at a PC bereavement program in Canada and participated to qualitative phenomenological interviews. Data Collection: Interpretative phenomenological analysis was used to analyze the data derived from in-depth interviews. Results: The participants' existential journeys can be described by three dynamic dimensions: (1) from avoidance to integration of death, (2) from meaninglessness to meaningfulness, and (3) from transformation to transmission. The findings highlight the importance to family caregivers of having opportunities to share their experiences as a way to progress on the existential journey. Conclusions: PC should extend beyond the death of the loved one and expand to include existential aspects of the caregiving experience.

Complicated grief knowledge, attitudes, skills, and training among mental health professionals: A qualitative exploration

The knowledge, attitudes, skills, and training of professionals regarding complicated grief influence their practice. We conducted 30 semi-structured interviews with psychiatrists, psychologists, and counselor/psychotherapists; the preliminary findings were contextualized via interviews with three experts in complicated grief research/practice. Findings suggest that professionals did not substantially rely on research evidence, favoring instead personal and professional knowledge. They expressed concern regarding the possible pathologization of normal grief that might arise from having a diagnosis of complicated grief. Deficits in professional training were evident. A need for an improved culture of collaboration between researchers and practitioners was identified.

Narratives of Self-Harm at School: Identifying Trajectories of Intervention in Educational Contexts

Recent studies have shown that self-harming behaviour is increasingly widespread among adolescents, in particular at school. However, educational institutions perceive themselves unable to cope with the phenomenon, searching for protocols and guidelines to improve its management. Considering schools as useful contexts for intercepting the young malaise, this study aims at exploring the main meanings of self-harming behaviours made within the educational cultural contexts starting from the student’s narrations, in order to understand the possible trajectories of practice. In two high schools we have collected 96 narratives of self-harm written by adolescents (mean age 14; 74% females), who have been engaged in non-suicidal self-injury once in their life. The analysis of the narratives, produced with the help of a software for the automatic qualitative analysis of texts, has allowed to identify four prevalent themes organized into three sense vectors. The findings highlighted significant gender differences in the representation of the experience of self-harm between males and females, as well as the importance of meaningful relationships developed in familiar and educational contexts, which may allow the help seeking process. The emerging of culturally-shared meanings among adolescents within the investigated contexts may allow to think about possible protocols of preventive and clinical practices in schools.

"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.