The role of avoidance in complicated grief: A detailed examination of the Grief-Related Avoidance Questionnaire (GRAQ) in a large sample of individuals with complicated grief

From loss to disorder: The influence of maladaptive coping on prolonged grief

Research indicates that post-bereavement coping strategies can be adaptive or maladaptive. Understanding which strategies lead to poorer outcomes is an important clinical and theoretical question with the potential to guide intervention. The Oxford Grief - Coping Strategies scale was developed from interviews with bereaved people with and without prolonged grief disorder (PGD) to assess the frequency of maladaptive cognitive and behavioural strategies after bereavement. Factorial and psychometric validity were assessed using exploratory and confirmatory factor analysis (N = 676). A three-wave cross-lagged panel model (N = 275) was used to assess the predictive validity of the tool in explaining symptoms of PGD. Results supported a four-factor solution (Avoidance, Proximity Seeking, Loss Rumination, Injustice Rumination) with good psychometric properties. The OG-CS predicted prospective symptoms of PGD in the short-term (6-12 months) and long term (12-18 months), controlling for baseline symptoms and autocorrelations. Subscale analyses demonstrated that the use of coping strategies predicted ICD-11 PGD in both the short-term and the long-term. However, avoidance was not predictive of outcomes early in the grieving process. At 6-12 months, avoidance predicted PGD at 12-18 months.

Neural correlates of deceased-related attention during acute grief in suicide-related bereavement

BACKGROUND

Individuals who have lost a loved one to suicide demonstrate an attentional bias to deceased-related stimuli during early grief. Regulating attention toward reminders of the deceased during acute bereavement may be linked to grief trajectory and pathological grief development. Despite the potential prognostic importance, little is known about underlying neural circuitry correlates of deceased-related grief processing. The current study examines neural substrates of deceased-related attentional processing during acute grief in individuals bereaved by suicide.

METHODS

Thirty-seven participants grieving the loss of a first-degree relative or partner to suicide in the prior six months, underwent functional magnetic resonance imaging (fMRI) while performing an emotional Stroop task using words related to the deceased and a living attachment figure, in order to examine neural correlates of deceased-specific attentional processing. Clinical interviews were conducted at baseline.

RESULTS

Deceased-related attentional bias was associated with blood oxygen level-dependent (BOLD) activation in a brain network, including dorsolateral prefrontal cortex (dlPFC), ventrolateral prefrontal cortex (vlPFC), orbitofrontal cortex (OFC), and insula. Greater activation of a bilateral prefrontal cluster during deceased-specific attention was negatively correlated with self-reported grief avoidance behaviors.

LIMITATIONS

Lack of non-suicide grief control and small sample size.

CONCLUSIONS

These data, if confirmed, indicate a neural network specific to deceased-related attention, and that cognitive control regions within this network appear to be related to grief avoidance behaviors during acute bereavement.

A pull to be close: The differentiating effects of oxytocin and grief stimulus type on approach behavior in complicated grief

Theoretical models of complicated grief (CG) suggest that maladaptive motivational tendencies (e.g., perseverative proximity-seeking of the deceased; excessive avoidance of reminders) interfere with a person's ability to recover from their loved one's death. Due in part to conflicting evidence, little mechanistic understanding of how these behaviors develop in grief exists. We sought to (1) identify behavioral differences between CG and non-CG groups based on approach/avoidance bias for grief-, deceased-, and social-related stimuli, and (2) test the role of the neuropeptide oxytocin in shaping approach/avoidance bias. Widowed older adults with (n = 17) and without (n = 22) CG completed an approach/avoidance task measuring implicit bias for both personalized and non-specific grief-related stimuli (among other stimuli). In a double-blinded, randomized, counterbalanced design, each participant attended both an intranasal oxytocin session and a placebo session. Aims were to (1) identify differential effects of CG and stimulus type on implicit approach/avoidance bias [placebo session], and (2) investigate interactive effects of CG, stimulus type, and oxytocin vs. placebo on approach/avoidance bias [both sessions]. In the placebo session, participants in the non-CG group demonstrated an approach bias across all stimuli. Intranasal oxytocin had an overall slowing effect on the CG group's response times. Further, oxytocin decreased avoidance bias in response to photos of the deceased spouse in the CG group only. Findings support the hypothesis that oxytocin has a differential effect on motivational tendency in CG compared to non-CG, strengthening evidence for its role in CG. Findings also emphasize the need to consider differences in personalized vs. generic stimuli when designing grief-relevant tasks.

Exploring the role of empathy in prolonged grief reactions to bereavement

Grief reactions to the bereavement of a close individual could involve empathy for pain, which is fundamental to social interaction. To explore whether grief symptoms interact with social relatedness to a person to whom one directs empathy to modulate the expression of empathy, we administered an empathy task to 28 bereaved adults during functional magnetic resonance imaging, in which participants were subliminally primed with facial stimuli (e.g., faces of their deceased or living relative, or a stranger), each immediately followed by a visual pain stimulus. Individuals' grief severity promoted empathy for the pain stimulus primed with the deceased's face, while it diminished the neural response to the pain stimulus primed with the face of either their living relative or a stranger in the medial frontal cortex (e.g., the right dorsal anterior cingulate cortex). Moreover, preliminary analyses showed that while the behavioral empathic response was promoted by the component of "longing" in the deceased priming condition, the neural empathic response was diminished by the component of "avoidance" in the stranger priming condition. Our results suggest an association between grief reactions to bereavement and empathy, in which grief symptoms interact with interpersonal factors to promote or diminish empathic responses to others' pain.

Attentional bias during acute grief predicts clinical outcome in suicide-related bereavement

BACKGROUND

Individuals who have lost a loved one to suicide are at increased risk for developing complicated grief (CG). It is unclear why only a subgroup of bereaved develops pathological forms of grief. Vulnerability may be related to the ability to regulate attention toward reminders of the deceased during the acute phase of grief. Using a longitudinal design, we determined whether loss-related attentional bias during acute grief predicts grief severity one year later.

METHODS

Thirty-seven participants grieving a first-degree relative or partner to suicide in the prior 6 months performed an emotional Stroop task using words related to the deceased, a living attachment figure, living non-attachment figure, and color congruent Stroop to quantify related attentional bias during the acute grief period. Clinical interviews were conducted at baseline (N = 37) and one year later (N = 35).

RESULTS

Participants showed greater attentional bias to deceased-related word trials compared with living attachment, non-attachment, and congruent trials, controlling for age, time since loss, depression, and psychiatric medication. A greater reduction in grief severity over time was associated with more deceased-related attentional bias at baseline. Self-reported grief avoidance was related to deceased-related attentional bias, with lower avoidance scores associated with greater bias.

LIMITATIONS

Lack of non-suicide grief control and small sample size.

CONCLUSIONS

Less deceased-related bias following the loss may hinder the transition from acute to integrated grief and result in poorer grief trajectories.

Entertainment-Education: What Are Grey's Anatomy and Saving Hope Teaching Us About Death?

In this article, we examine primetime television as a source of entertainment-education on death. Using directed (deductive) and conventional (inductive) approaches to content analysis, we describe how death and dying are being depicted on two primetime medical television series, Grey's Anatomy and Saving Hope. We then discuss what kinds of information viewers may be taking from these series. Our deductive content analysis suggests that much of the messages obtained are fairly representative of what occurs in real hospital settings, with the exception of emotional display. From the inductive analysis, we identified four thematic categories: 'the person dies, but life goes on', 'the tragic death', 'the purposeful death', and 'the well-timed death'. Regardless of category, no rituals are conducted at the moment of death and little space is made for grieving on primetime medical television shows. While death is often present, displays of grief are avoided.

Parental death: a systematic review of support experiences and needs of children and parent survivors

BACKGROUND

Bereaved people need a supportive response from those around them. Knowing children's and surviving parents' needs following parental death is the first step to ensuring a supportive response. However, no systematic review has reported on this phenomenon.

AIM

To systematically identify and synthesise qualitative literature exploring support experiences of parentally bereaved children and surviving parents.

METHODS

Systematic review with thematic synthesis, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE, Embase, PsycINFO, CINAHL and the British Nursing Database were searched for relevant papers to September 2021. Included studies were appraised for quality and thematically synthesised using Thomas and Harden's thematic synthesis framework.

RESULTS

Fifteen qualitative studies from nine countries were included. There were four analytical themes from the children's perspectives (1) Openness of communication with children about death and dying, (2) Children's challenges of managing change, (3) Navigating emotions, and (4) Children's acceptability, access and engagement with support. There were three analytical themes from the parents' perspectives: (1) Adjusting as a parent, (2) Supporting their children, and (3) Parent's acceptability, access and engagement with support.

CONCLUSIONS

Following a parental death, open and honest communication and involvement in what is happening within the family will help children cope. Both children and parents suppress emotions and avoid conversations to protect each other and those around them. A taboo around death exists and constrains the support some families receive. Childhood bereavement is a public health issue, with a need for professionals and communities to better understand and respond to the needs of bereaved families.CRD42020166179.

Change in avoidance and negative grief-related cognitions mediates treatment outcome in older adults with prolonged grief disorder

Objective: The present study investigated the role of the two theoretically derived mediators in the treatment of Prolonged Grief Disorder (PGD). Mediators were changes in avoidance and maladaptive cognitions. An additional hypothesis tested whether these candidate mediators are specific to CBT-based Complicated Grief Treatment (CGT) compared to Interpersonal Therapy (IPT). Method: We performed secondary analyses with assessment completers (n = 131) from a randomized-controlled trial with older adults with PGD. Patients received 16 sessions of CGT or IPT. Outcomes were treatment response and reductions in grief symptoms and grief-related related impairment. Results: Reductions in avoidance between baseline and week 16 mediated reductions in grief symptoms and grief-related impairment. Reductions in maladaptive grief-related cognitions over the same period mediated treatment response, reductions in grief symptoms and grief-related impairment. There were no significant treatment-mediator interactions. We could not establish that mediators changed before the outcomes. Conclusion: Results are consistent with theoretical models of PGD, including the CGT treatment model. Despite different therapeutic procedures, we found no significant interaction effect, but CGT produced larger effects. Future research needs to establish a timeline of change through the use of multiple measurements of mediators and outcomes.Trial registration: ClinicalTrials.gov identifier: NCT01244295.

Polygenic risk for traumatic loss-related PTSD in US military veterans: Protective effect of secure attachment style

OBJECTIVES

To examine whether attachment style moderates the relationship between polygenic risk scores (PRS) for posttraumatic stress disorder (PTSD) re-experiencing (PTSDREX) symptoms and the severity of and positive screen for traumatic loss-related PTSD.

METHODS

Data were analysed from 631 US veterans who endorsed 'unexpected death of a loved one' as their 'worst' traumatic event. Multivariable models evaluated the association between PRS for PTSDREX, attachment style, and their interaction in predicting severity and positive screen for PTSD. A gene enrichment analysis was conducted to identify possible molecular mechanisms underlying the association between PTSDREX PRS and PTSD.

RESULTS

PTSDREX PRS (β = 0.17; odds ratio [OR] = 1.85), attachment style (β= -0.33; OR = 0.14), and PTSDREX PRS × attachment style interaction (β= -0.12; OR = 0.53) were significant predictors of the severity and positive screen for PTSD. The most significant gene set detected was the gene ontology (GO) cellular component podosome set (GO:0002102, p < 3.95 × 10-5).

CONCLUSIONS

Having a secure attachment style may help mitigate polygenic risk for developing traumatic loss-related PTSD in US veterans. Podosomes, which are implicated in inflammatory and neuroplasticity processes, may contribute to the genetic liability to developing loss-related PTSD. Psychological treatments targeting attachment security may help mitigate increased polygenic risk for loss-related PTSD in this population.

Why Are Dying Individuals Stigmatized and Socially Avoided? Psychological Explanations

Extant research on the topic of death and dying in modern society frequently includes the observation that death is now rendered invisible, and dying individuals are stigmatized and socially avoided. The current research speculated that lack of contact with a dying individual may promote negative perceptions of the dying, and this may in turn lead to further avoidance of them. Three studies were conducted: The first study examined how frequently the current U.S. participants had social contact with a dying individual; the second study investigated what perceptions they have of the dying, and the third study tested for potential causal links between negative perceptions of the dying and social avoidance of them. The results indicated: Only a small number of the U.S. participants ever had frequent social contact with a dying individual outside their family; they, nevertheless, shared several common negative perceptions of the dying; and those negative perceptions exerted different effects on one's avoidant attitude toward a dying individual-only making males more avoidant, especially in a physically close social relationship. Two concepts, medicalization and masculinism, were suggested as possible explanations for why dying individuals are stigmatized and avoided in modern society.

"I Feel All Alone Out Here": Analysis of Audio Diaries of Bereaved Hospice Family Caregivers During the COVID-19 Pandemic

The COVID-19 pandemic has dramatically changed social life. This secondary qualitative analysis aimed to better understand the impact of the pandemic on bereaved hospice family caregivers' experiences of social connection and isolation in a time of social distancing and general anxiety. Six caregivers in 3 states recorded audio diaries (N = 59) between March 13 and May 15, 2020. Caregivers were, on average, 56.80 years old (SD, 14.22; range, 32-67 years old) and consisted of spouses (n = 2), adult children (n = 3), and a sibling (n = 1). Using NVIVO 12, caregiver diaries were coded for (1) "social connection" (n = 23), defined as being able to access or seeking informal or formal social support networks; (2) "isolation" (n = 17), defined as being unable or reluctant to access informal or formal social support networks, or feeling alone; and (3) "bereavement processes" (n = 147), informed by the dual process model of bereavement (restoration and loss-oriented stressors). Content analysis revealed that caregivers were able to connect with others despite physical distancing expectations, expressed loneliness and grief while in isolation, and described moving on in the face of uncertainty. Findings provide insight into how caregivers experienced bereavement during the initial period of the pandemic and highlight implications for hospice bereavement services.

Horror Films and Grief

Many of the most popular and critically acclaimed horror films feature grief as a central theme. This article argues that horror films are especially suited to portraying and communicating the phenomenology of grief. We explore two overlapping claims. First, horror is well suited to represent the experience of grief, in particular because the disruptive effects of horror “monsters” on protagonists mirror the core experience of disruption that accompanies bereavement. Second, horror offers ways in which the experience of grief can be contained and regulated and, in doing so, may offer psychological benefits for the bereaved. While our focus will be squarely on film, much of what we say applies to other media.

A scoping research literature review to map the evidence on grief triggers

Grief is understandably severe in the first days, if not weeks or months, following the death of a beloved person. Unless the mourner develops complicated grief, which is prolonged severe and impactful grief, the initial acute grief lessens in severity over time, although waves of significant grief will still occur with grief triggers. A scoping research literature review was undertaken in early 2021 to determine how often grief triggers occur, what the most common grief triggers are, the impact of triggered grief, and what can be done (by those not diagnosed with complicated grief) to manage grief triggers and mitigate the effect of them. Nine academic library databases were searched for English-language research reports using the keywords "grief trigger(s)" and "research": CINAHL, Directory of Open Access (online) Journals, Humanities Index, JSTOR, Medline (Ovid), Periodicals Index Online, PsychArticles, Scopus, and Web of Science. Six research papers relevant for review were published in the last two decades, with some evidence gained on how often grief triggers occur, what constitutes a grief trigger, and the impact of grief triggers. Major gaps in evidence were revealed, despite grief triggers being identified as a major consideration for grief in general and for grief recovery specifically.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Masking of Mourning: Social Disconnection After Bereavement and Its Role in Psychological Distress

Social support has been shown to facilitate adaptation after bereavement in some studies but not others. A felt sense of social disconnection may act as a barrier to the utilization of social support, perhaps explaining these discrepancies. Factorial and psychometric validity of the Oxford Grief-Social Disconnection Scale (OG-SD) was tested in a bereaved sample (N = 676). A three-factor solution (negative interpretation of others’ reactions to grief expression, altered social self, and safety in solitude) fit the data best and demonstrated excellent psychometric validity. A second three-wave longitudinal sample (N = 275) recruited 0 to 6 months following loss and followed up 6 and 12 months later completed measures of prolonged grief disorder, posttraumatic stress disorder, depression, and the OG-SD at each time point. High levels of baseline social disconnection were associated with concurrently high psychological distress. The extent to which social disconnection declined over time predicted resolution of psychological distress.

Deepening the understanding of complicated grief among Chinese older adults: A network approach

Instead of understanding symptoms in a way where a latent cause exists and symptoms serve as its indicators, the network approach enables an innovative comprehension on psychological disorders that focuses on causal interactions. There is need to update the knowledge in this direction in Chinese context. This study strives to apply network approach to deepening the understanding of complicated grief (CG) among older adults in rural China. A sample of older participants (N = 352) who experienced spousal bereavement living in Zhejiang Province of China were administrated with face-to-face interviews. Networks analysis was conducted to realize the object of this study. The 19-item ICG network revealed that symptoms were both positively and negatively connected within the network. The most three central symptoms were "feeling longing for the person who died" and "memories of the dead", and feeling lonely". Edge-weights accuracy and centrality stability were tested in order to remind carefulness when interpreting the results. This study demonstrates the utility of a network approach in deepening the understanding of the structure of CG symptoms among Chinese older people. Strengths and limitations, as well as implications for informing the assessment and treatment of this disorder, were discussed.

Intensive outpatient treatment of PTSD and complicated grief in suicide-bereaved military widows

We report on a novel 2-week intensive outpatient treatment program (IOP) for 24 widows bereaved by the suicide death of their veteran spouse. We targeted symptoms of posttraumatic stress disorder (PTSD) and complicated grief (CG) concurrently in three separate cohorts. All patients either witnessed the death or discovered the body of their deceased partner, who was a veteran of the United States military. PTSD, CG, and depression symptom severity decreased significantly from pre- to post-treatment, with effect sizes of 0.85, 1.21, and 1.35, respectively. These outcomes provide preliminary support for an IOP to treat co-occurring PTSD and CG among widowed survivors of veteran suicide.

Commentary on evidence in support of a grief-related condition as a DSM diagnosis

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice

In the United States alone, about 10 million persons are newly bereaved each year. Most do not require professional intervention or treatment, but many can benefit from targeted support. However, a significant minority of bereaved persons experience intense, prolonged and disabling grief symptoms associated with considerable morbidity and mortality (aka, "Complicated Grief"). Individuals with Complicated Grief require more formal interventions. In this article, we describe a compassionate and evidence-based approach to bereavement-care that can be provided in varied mental health settings. For individuals struggling with acute grief, clinicians can help by providing recognition and acceptance of the grief, eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly "checking in" regarding their grief experiences. For bereaved persons who are experiencing Complicated Grief, we recommend an evidence-based approach to bereavement-care, complicated grief therapy (CGT), that involves helping the individual accept and cope with the loss while simultaneously assisting them with adaptation to life without the deceased. We describe ways of implementing CGT's seven core themes: (1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died. This work can be done in a variety of settings, taking into consideration the needs of the patient, the limitations of the setting, and the skills and experiences of each clinician.

An investigation of approach behaviour in Prolonged Grief

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

Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes

BACKGROUND

Suicide bereavement is a risk factor for adverse outcomes related to grief, social functioning, mental health and suicidal behaviour. Consequently, suicide bereavement support (i.e., postvention) has been identified as an important suicide prevention strategy. However, little is known about its effectiveness. To redress this gap, this review aimed to assess the evidence of effectiveness of interventions for people bereaved by suicide, and appraise the quality of the research in this field.

METHODS

We conducted a systematic review according to PRISMA guidelines. Searches of peer-reviewed literature in Medline, PsycINFO, Embase and EBM Reviews identified 12 papers reporting on 11 relevant studies conducted between 1984 and 2018.

RESULTS

Across studies, there was a wide variety of intervention modalities, study populations, control groups, and grief, psychosocial and suicide-related outcome measures. Overall, the quality of studies was weak. While there was some evidence of the effectiveness of interventions for uncomplicated grief, evidence of the effectiveness of complicated grief interventions was lacking. Based on this scant evidence, interventions which seem to show promise include supportive, therapeutic and educational approaches, involve the social environment of the bereaved, and comprise a series of sessions led by trained facilitators.

CONCLUSIONS

There is a clear need for additional methodologically sound studies in this area. Specifically, selection procedures, sample sizes, randomization, and the use of appropriate measures are crucial. As people bereaved by suicide are at-risk of adverse grief, mental ill-health and suicidal behaviour, further research across the life-span is essential to prevent grief and mental health ramifications.

Examination of factor structure of the inventory of complicated grief (ICG) in a sample of bereaved military family members with persistent and elevated grief

Knowledge about the effect of a US service member's death on surviving family members is limited. In order to identify their grief-related health care needs, a first step is to identify the characteristics of persistent and elevated grief in a military family sample. The present study identified military family members (n = 232) bereaved more than six months who endorsed an elevated level of grief. A confirmatory factor analysis and test of measurement invariance of factor structure were used to compare the factor structure of their Inventory of Complicated Grief (ICG) responses to that of a bereaved non-military-related clinical research sample with similar grief levels. Results confirmed an equivalent five-factor structure of the ICG in both the military family sample and the clinical research sample. The similarity in factor structure was present despite differences in demographic characteristics and bereavement experiences between samples. Thus, the ICG reliably measures persistent and elevated grief in military family samples and provides grief symptom profiles that facilitates better understanding of their grief-related needs.

Performance and psychometric properties of the Interpersonal Support Evaluation List (ISEL) in older adults with Complicated Grief

BACKGROUND

Complicated Grief (CG) is a recently recognized bereavement-related mental health disorder. Social support is commonly measured with the Interpersonal Support Evaluation List (ISEL), a 40-item, 4-factor, self-report measure. Though the ISEL has been well-studied, no identified research has examined its psychometric properties or performance in older adults with CG.

METHODS

We examined the psychometric properties of the ISEL in adults age ≥60 who enrolled in a psychotherapy treatment study for CG in New York City. We also examined the association of ISEL scores with CG severity, and with clinical and sociodemographic variables.

RESULTS

Internal consistency of the ISEL was high (α=0.95). Confirmatory factor analysis indicated that most of the ISEL items loaded strongly (>0.45) on the original 4 factors. Mean ISEL score was 68.1, which indicated lower social support than population norms. ISEL scores were significantly but modestly negatively correlated with grief severity. ISEL total scores also varied by sociodemographic and clinical variables; never being married, depression or anxiety diagnosis, and living alone were all associated with lower ISEL scores.

LIMITATIONS

A clinical help-seeking sample, with low sociodemographic and geographic variability, may limit the generalizability of the findings. Also, analyses were cross-sectional and directionality of associations could not be determined.

CONCLUSIONS

The 40-item ISEL may be a useful measure for those studying social support in the context of CG. Given the strikingly low levels of social support, intervention strategies for CG should include components addressing social support.

Networks of loss: Relationships among symptoms of prolonged grief following spousal and parental loss

The death of a loved one can trigger a range of emotional, behavioral, motivational and cognitive reactions collectively labeled as "grief." There has been a recent resurgence of empirical interest in grief reactions, and there is now a general consensus that 7%-10% of bereaved individuals experience intense and chronic reactions termed Prolonged Grief (PG). However, there is ongoing debate about how best to conceptualize the construct. Recent studies have advanced this debate by applying a network, or causal systems approach. Whereas traditional views of psychopathology posit symptoms of disorders reflect the independent actions of latent entities, the network approach argues that the symptoms themselves interact to give rise to the disorder. A network conceptualization offers novel approaches to studying the mechanisms that contribute to PG. To date, however, research has focused only on spousal loss and only used a single archival data set. Therefore, in this paper we apply network analysis to examine relationships among PG symptoms in samples of individuals bereaved by loss of a spouse (Study 1, N = 193) and a parent (Study 2, N = 180). Participants completed the PG-13 and a measure of depression. A comparison test suggested the networks produced from each sample were not reliably different. The strongest link in both networks was between yearning and emotional pain. Meaninglessness was relatively central, whereas avoidance was peripheral in both networks. Findings are discussed with reference to theoretical models and the potential benefits a network approach may hold for understanding relationships between symptoms of PG. (PsycINFO Database Record

Predictors of treatment response for cognitive behaviour therapy for prolonged grief disorder

Background: Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive behaviour therapy (CBT) has been shown to effectively treat PGD, there is a need to identify predictors of treatment non-response. Methods: PGD patients (N = 80) were randomly allocated to receive 10 weekly two-hour group CBT sessions and (a) four individual sessions of exposure therapy or (b) CBT without exposure. PGD was assessed by self-report measures at baseline, post-treatment (N = 61), and six-months (N = 56) after treatment. Results: Post-treatment assessments indicated that greater reduction in grief severity relative to pretreatment levels was associated with being in the CBT/Exposure condition, and lower baseline levels of self-blame and avoidance. At follow-up, greater grief symptom reduction was associated with being in the CBT/Exposure condition and lower levels of avoidance. Conclusions: These patterns suggest that strategies that target excessive self-blame and avoidance during treatment may enhance response to grief-focused cognitive behaviour therapy.