Inventory of complicated spiritual grief: development and validation of a new measure

Perinatal Loss and Parents' Grief Amidst the COVID-19 Pandemic: A Mixed-Method Research

Losing a child is a traumatic event, disrupting life's natural cycle, profoundly affecting the family system, and causing enduring grief. Perinatal death, including ectopic pregnancies, miscarriages, stillbirths, and neonatal deaths, exacerbates this distress. Additionally, the COVID-19 pandemic has challenged healthcare systems and supporting services available to individuals in need. Thus, this research explores experiences of parents facing perinatal loss in 2020-2021, further focusing on the pandemic's impact. Using a mixed-methods design with self-reports and qualitative interviews, this paper presents results from the quantitative protocol, involving an update and follow-up of a previous study. It compares measurements across scales: COVID-19: The Impact of Event Scale-Revised; The Prolonged Grief-13; The Parental Assessment of Paternal/Maternal Affectivity; The Dyadic Adjustment Scale (short version); The Daily Spiritual Experiences Scale; and The Inventory of Complicated Spiritual Grief. In the baseline measurement, 45 parents participated (37 mothers and 8 fathers), with 20 (13 mothers and 7 fathers) contributing to the follow-up and 9 engaging in interviews. Baseline results showed higher scores for mothers compared to fathers, with effect sizes ranging from small to medium (ranging from -0.02 to 0.29), though statistical significance was limited due to the small sample size. Multiple regression analysis for distress measures at baseline identified two significant predictors: maternal/paternal affectivity and gestational week. Additionally, positive support from healthcare professionals emerged as a mitigating factor, particularly in relation to Avoidance. A significant reduction in stress measures and parental affectivity was observed at the 6-month follow-up. Qualitative analysis revealed three themes: Shifts in Self-Perception and Post-Loss Growth; Conflicted Relationship with One's Body; and Negative Impact of COVID-19 vs. Unexpectedly Positive Aspects. In conclusion, the findings emphasize the significance of psychological and psychosocial interventions based on meaning-making processes, along with the importance of spiritual care and empowerment for those navigating perinatal loss.

The Impact of COVID-19 on Grief: A Quantitative and Qualitative Analysis in Italy

This mixed-method research study delves into the repercussions of the COVID-19 pandemic on loss and mental health in Italy. The analysis uncovers a significant correlation between COVID-19 fear and heightened anxiety, depression, and stress, exacerbated by social isolation and misinformation. The loss of loved ones during the pandemic intensifies distress, with 28% showing signs of prolonged disorder and 22.8% displaying maladaptive grief symptoms. Distress persists across pandemic phases (59.3% critical, 54.9% intermediate, 48.4% less critical), attributed to grief, fear, uncertainty, and isolation. Qualitative analysis identifies two core themes: 'Death without Dying' and 'Online Grieving Practices and Coping Strategies,' elucidating disruptions to traditional grieving and the role of online coping strategies. Our findings underscore the pandemic's multifaceted impact on grief and mental health in Italy, highlighting the importance of addressing social and emotional needs during crises.

Battles of the Soul: Validation of the Scale of Religious and Spiritual Struggles (RSS) for the Portuguese Population

This study aims to adapt and validate the Religious and Spiritual Struggles Scale for the Portuguese population. The sample consisted of 732 participants with various religious affiliations. The exploratory factor analysis showed that it consists of six dimensions, similar to the initial instrument. A KMO of 0.91 was obtained. The confirmatory factor analysis confirmed the existence of six factors and showed adequate fit indices. Internal consistency and construct reliability were above 0.70. The analysis of the psychometric qualities of this instrument indicates that it can be applied to the Portuguese population and is a valuable instrument for psychotherapeutic practice and studies in the psychology of religion and spirituality.

The Impact of the COVID-19 Pandemic on Perinatal Loss Experienced by the Parental Couple: Protocol for a Mixed Methods Study in Italy

Background

At the beginning of 2020, mothers and fathers who experienced perinatal events (from conception to pregnancy and postpartum period) found themselves facing problems related to the emergency caused by the COVID-19 pandemic and the associated difficulties for health care centers in providing care. In the unexpected and negative event of perinatal loss (ie, miscarriage, stillbirth, and neonatal death) more complications occurred. Perinatal loss is a painful and traumatic life experience that causes grief and can cause affective disorders in the parental couple—the baby dies and the couple’s plans for a family are abruptly interrupted. During the COVID-19 pandemic, limited access to perinatal bereavement care, due to the lockdown measures imposed on medical health care centers and the social distancing rules to prevent contagion, was an additional risk factor for parental mental health, such as facing a prolonged and complicated grief.

Objective

The main aims of this study are as follows: to investigate the impact of COVID-19 on mothers and fathers who experienced perinatal loss during the pandemic, comparing their perceptions; to evaluate their change over time between the first survey administration after bereavement and the second survey after 6 months; to examine the correlations between bereavement and anxiety, depression, couple satisfaction, spirituality, and sociodemographic variables; to investigate which psychosocial factors may negatively affect the mourning process; and to identify the potential predictors of the development of complicated grief.

Methods

This longitudinal observational multicenter study is structured according to a mixed methods design, with a quantitative and qualitative section. It will include a sample of parents (mothers and fathers) who experienced perinatal loss during the COVID-19 pandemic from March 2020. There are two phases—a baseline and a follow-up after 6 months.

Results

This protocol was approved by the Ethics Committee of Psychological Research, University of Padova, and by the Institutional Ethics Board of the Spedali Civili of Brescia, Italy. We expect to collect data from 34 or more couples, as determined by our sample size calculation.

Conclusions

This study will contribute to the understanding of the psychological processes related to perinatal loss and bereavement care during the COVID-19 pandemic. It will provide information useful to prevent the risk of complicated grief and psychopathologies among bereaved parents and to promote perinatal mental health.

International Registered Report Identifier (IRRID)

DERR1-10.2196/38866

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.

Conflicts Between Women's Religiosity and Sense of Free Will in the Context of Elective Abortion: A Qualitative Study in the Worst Period of Italy's COVID-19 Crisis

This qualitative study considers the relationship between abortion, bereavement, and the effects of the COVID-19 lockdown nine women who had undergone an elective abortion, which is voluntarily termination of a pregnancy at the woman's request. These women were interviewed in three time points (1 month, 6 months, and 1 year after the event) to consider the possible evolution of their experience. The third phase was concurrent with the COVID-19 pandemic and particularly with Pope Francis's Easter declaration against abortion. All the interviews were conducted and analysed through qualitative research in psychology. Results showed that the abortion experience led to physical, relational, and psychological suffering, similar to perinatal grief. Participants were non-practising Catholics and religiosity did not help them to overcome their sorrow. Though religiosity is a possible resilience factor in other stressful conditions, in this case it is a factor that aggravated suffering. Finally, we discuss the difficulties experienced by Catholic women who choose to have an abortion and assert the necessity of psychological and spiritual interventions to support these women.

Use of Spirituality to Make Sense of Loss by Homicide

This article presents a magnification of Stage 2 of the Theory of Post-Homicide Spiritual Change, a three-stage grounded theory of spiritual change after homicide (Theory of PHSC). Having endured the disintegration of their belief systems in the immediate aftermath of murder (Stage 1), survivors turn in Stage 2 to a more extended process of grappling with a crisis of meaning. This Stage 2 process is presented within the framework of the meaning making model, with attention to spiritual meaning making and transcendental experiences. Findings can help service providers support homicide survivors throughout an intermediary stage of bereavement that is marked by a sense of stagnation and diminished well-being. By accompanying survivors through the difficult meaning making efforts that characterize this stage, providers can help position them to break free of intensive cognitive meaning making and gain forward momentum in Stage 3 of the Theory of PHSC and can focus on aspects of life that can help them successfully make meaning of their loss while positioning them to gain forward momentum.

Understanding the spirituality of parents following stillbirth: A qualitative meta-synthesis

This meta-synthesis aims to synthesize qualitative evidence from primary studies to better understand the experience of the spirituality of parents and its relationship to adapting following stillbirth. Five electronic databases were systematically searched and the quality of 21 eligible studies was critically appraised. A thematic synthesis revealed two analytical themes: (1) Spiritual suffering following stillbirth; (2) Moving through spirituality to adapt to the loss, each encompassing four descriptive themes. The findings can inform a more culturally and spiritually sensitive approach to care, taking into account the parents' beliefs, folk customs, religion, values, and spiritual needs.

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.

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.

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.

The use of pathological grief outcomes in bereavement studies on African Americans

Pathological bereavement outcomes (i.e., complicated grief, traumatic grief, prolonged grief disorder) are a robust and growing research area in the psychological and medical sciences. Although grief is considered to be a universal phenomenon, it is well documented that grieving processes and outcomes are culturally and contextually bound. The objectives of this study were: (a) to examine representations of African Americans in the grief and mourning literature and to assess the extent to which this research utilizes pathological grief outcomes; and (b) to examine the characteristics of pathological grief constructs in the literature to assess their relevance for African American populations. We conducted comprehensive searches of three scientific databases including PsycNET, Medline, and CINAHL, which contain the majority of grief and mourning literature published between January 1998 and February 2014. We found 59 studies addressing grief and mourning in African Americans. Thirteen of these studies used pathological grief outcomes. Pathological grief outcomes that were constructed and validated on White populations were frequently used as outcome variables with African American participants. We discuss the implications for the grief and mourning field and argue that the failure to use culturally sensitive outcome measures in research studies is a form of epistemological violence that may have negative research and clinical implications for African Americans and other ethnic minorities.

Meaning Reconstruction in the Wake of Loss: Evolution of a Research Program

As theories of bereavement have evolved, so too have evidence-based interventions to mitigate complications in post-loss adaptation. This article reviews one line of programmatic research grounded in a conceptualisation of grieving as an attempt to reaffirm or reconstruct a world of meaning challenged by loss. Anchored in therapeutic encounters with the bereaved, a meaning reconstruction approach to loss has grown over the past 15 years to generate an increasingly substantial research base, as well as to develop and refine a wide array of contributions to psychological assessment and therapy. By summarising the major models, measures and methods resulting from this collaborative work, it offers an introduction to meaning reconstruction for those unfamiliar with it, noting its contributions to date, its areas of future development, and its relevance for clinical practice.

The role of religious affiliation in Christian and unaffiliated bereaved emerging adults' use of religious coping

Though research on bereavement has grown, few studies have focused on emerging adults. To add to the literature, the authors administered the RCOPE to a sample of bereaved college students (analyzed sample N = 748) and explored the relationship between self-reported religious affiliation and religious coping strategies used and endorsed as "most helpful." Results highlight the rich topography of bereavement previously unexamined in understudied populations (i.e., emerging adults, religiously unaffiliated). Specifically, the Christians/affiliated used "negative" religious coping strategies most often, yet identified "positive" strategies as "most helpful," whereas the unaffiliated instead used "positive" strategies most often and identified "negative" strategies as "most helpful."

Representations of African Americans in the Grief and Mourning Literature from 1998 to 2014: A Systematic Review

The authors examined representations of African Americans in the grief literature to assess (a) frequencies; (b) content; and (c) use of universalist or a contextualized framework. They conducted searches in 3 databases that target the grief literature published in the last 15 years. Fifty-nine articles met the criteria. There are a small number of studies published on African Americans and these tend to focus on homicide. Many studies had incomplete methods. Comparison studies were common and pathological grief outcomes that were validated on White populations were used as outcome variables with African American participants.

The Grief and Meaning Reconstruction Inventory (GMRI): Initial Validation of a New Measure

Although increasing numbers of grief theorists, researchers, and therapists have begun to focus on the quest for meaning in lives disrupted by loss, no convenient and psychometrically validated measure of meanings made specifically in bereavement has been available to guide their efforts. To construct such a measure, the authors began with a systematic content analysis of sense-making, benefit finding, and identity reconstruction themes gleaned from the narrative responses of a sample of 162 adults who were diverse in their age, ethnicity, relationship to the decedent, cause of death, and severity of their grief response. These were then formulated into a set of 65 candidate items in a Likert scale format representing the level of the respondent's endorsement of the item in the past week. Subsequent administration to a second sample of 300 bereaved respondents permitted factor analysis of this pilot version of the Grief and Meaning Reconstruction Inventory (GMRI), and reduced the items to 29, which loaded on 5 distinct factors, labeled Continuing Bonds, Personal Growth, Sense of Peace, Emptiness and Meaninglessness, and Valuing Life. Both the overall GMRI and its constituent factors showed good internal consistency and strong convergent validity in the form of negative correlations with established measures of bereavement-related negative emotions, symptoms of complicated grief, and more general psychological distress and mental health symptomatology, and positive correlations with grief related personal growth. The authors close by noting several specific research and clinical applications of the measure, which could play a useful role in testing and refining contemporary models of meaning made in the wake of loss.

Risk Factors for Anticipatory Grief in Family Members of Terminally Ill Veterans Receiving Palliative Care Services

Anticipatory grief is the process associated with grieving the loss of loved ones in advance of their inevitable death. Because anticipatory grief has been associated with a variety of outcomes, risk factors for this condition deserve closer consideration. Fifty-seven family members of terminally ill, hospice-eligible veterans receiving palliative care services completed measures assessing psychosocial factors and conditions. Elevated anticipatory grief was found in families characterized by relational dependency, lower education, and poor grief-specific support, who also experienced discomfort with closeness and intimacy, neuroticism, spiritual crisis, and an inability to make sense of the loss. Thus, in this sample, anticipatory grief appears to be part of a cluster of factors and associated distress that call for early monitoring and possible intervention.

The Persistent Complex Bereavement Inventory: A Measure Based on the DSM-5

The Persistent Complex Bereavement Inventory (PCBI) was developed to facilitate research into the construct of persistent complex bereavement disorder (PCBD). Across 2 studies, the PCBI yielded a stable 3-factor structure that corresponded with DSM-5 criteria for PCBD. The PCBI demonstrated solid reliability in the forms of internal consistency and test-retest reliability. Correlation analyses provided evidence of the measure's construct, convergent, and divergent validity. The PCBI predicted outcomes, above and beyond measures of prolonged grief disorder, separation anxiety, depression, and post-traumatic stress. In addition, the Social/Identity Disruption subscale was able to predict future negative religious coping, harmful health behaviors, hallucinations, somatic complaints, medical conditions, and suicidal ideation. This article provides preliminary evidence for a reliable and valid way to measure PCBD symptomatology.

A social constructionist account of grief: loss and the narration of meaning

In contrast to dominant Western conceptions of bereavement in largely intrapsychic terms, the authors argue that grief or mourning is not primarily an interior process, but rather one that is intricately social, as the bereaved commonly seek meaning in this unsought transition in not only personal and familial, but also broader community and even cultural spheres. The authors therefore advocate a social constructionist model of grieving in which the narrative processes by which meanings are found, appropriated, or assembled occur at least as fully between people as within them. In this view, mourning is a situated interpretive and communicative activity charged with establishing the meaning of the deceased's life and death, as well as the postdeath status of the bereaved within the broader community concerned with the loss. They describe this multilevel phenomenon drawing first on psychological research on individual self-narratives that organize life experience into plot structures that display some level of consistency over time, whose viability is then negotiated in the intimate interpersonal domain of family and close associates. Second, they explore public communication, including eulogies, grief accounts in popular literature, and elegies. All of these discourses construct the identity of the deceased as he or she was, and as she or he is now in the individual and communal continuing bonds with the deceased. Finally, they consider different cultural contexts to see how expressions of grief are policed to ensure their coherence with the prevailing social and political order. That is, the meanings people find through the situated interpretive and communicative activity that is grieving must either be congruent with the meanings that undergird the larger context or represent an active form of resistance against them.

Complicated spiritual grief II: a deductive inquiry following the loss of a loved one

Recent studies have revealed an association between complicated grief-a severe, prolonged response to the loss of a loved one-and complicated spiritual grief-a spiritual crisis following loss. Furthermore, bereavement research has benefitted from a number of studies using qualitative inquiry as a means of examining the experiences of individuals grieving a variety of types of losses. However, a gap in the literature remains in terms of the qualitative investigation of spiritual struggle following loss. Thus, using participants' written responses to open-ended questions along with systematic exploration of this topic with a five-member focus group, we designed this qualitative study to better understand the firsthand experiences of bereaved individuals who have suffered a crisis of faith after the death of a loved one. Specifically, our directed content analysis of bereaved focus group members' responses revealed 17 different common and salient themes subsumed in an overarching narrative of resentment and doubt toward God, dissatisfaction with the spiritual support received, and substantial changes in the bereaved person's spiritual beliefs and behaviors. Thus, our study clarified the construct of complicated spiritual grief, and laid the groundwork for development of more specific assessment and treatment of this condition.

Complicated spiritual grief I: relation to complicated grief symptomatology following violent death bereavement

Losing a loved one to violent death has been associated with poor mental health outcomes, including posttraumatic stress disorder, depression, and complicated grief (CG), a protracted, debilitating, and sometimes life-threatening reaction to loss. In addition, recent research suggests that traumatic loss can violate mourners' basic assumptive worldviews, and can precipitate a spiritual crisis following loss, also known as complicated spiritual grief (CSG). The present cross-sectional study investigated these multidimensional outcomes in a diverse sample of 150 grievers. The authors found that (a) violently bereaved individuals reported greater CG and CSG than did individuals bereaved by natural death; (b) CG and CSG were correlated across the larger sample, and yet are theoretically different constructs; and (c) specific cause of death (natural anticipated, natural sudden, homicide, suicide, or fatal accident) differentially predicted levels of CG and CSG. Implications of these findings for a clearer understanding of spiritual coping in the wake of troubling loss are noted, as well as for intervention with mourners struggling with clinical complications.

Inventory of complicated spiritual grief: development and validation of a new measure

Although spirituality often has been associated with better outcomes following bereavement, it can be significantly challenged by loss as well. Studies have shown that some bereaved individuals suffer profoundly not only in relation to the death of their loved one but also in their relationship with God and their faith community, a condition known as complicated spiritual grief (CSG). However, to date, in the absence of a simple, multidimensional, and well-validated measure of spiritual crisis following loss, investigators have measured CSG with nongrief-specific instruments. In this study, the authors tested the reliability and validity of a newly developed measure of CSG, called the Inventory of Complicated Spiritual Grief (ICSG). With 2 diverse samples of bereaved adult Christians (total n = 304), the authors found that the ICSG had strong internal consistency, and high test-retest reliability for both subscales in a subsample of participants. Analyses of both samples supported a 2-factor model, with one factor measuring Insecurity with God and the other assessing Disruption in Religious Practice. Analyses further supported the convergent and incremental validity of the 18-item ICSG relative to other theoretically similar instruments and measures of poor bereavement outcome, suggesting its usefulness in clinical research and practice.