"Cycling around an emotional core of sadness": emotion regulation in a couple after the loss of a child

Between loss and restoration: The role of liminality in advancing theories of grief and bereavement

A recent national survey of bereaved partners found high levels of complicated grief and psychological distress, with evidence that loneliness and isolation may contribute to these outcomes. However, the mechanisms of action for this have not been explored. To advance grief theory this paper reports analysis of the survey free-text data to examine the relationship between social support and emotional responses to bereavement. Individuals bereaved of a civil partner or spouse 6-10 months previously were identified through death registration data. 569/1945 (29 %) completed surveys were received. Of those, 311 participants (55 %) provided responses to two free-text questions which asked about their 'feelings since the death of their partner or spouse', and 'about the support around' them. Data were analysed using corpus-assisted discourse analysis and the discourse dynamics approach for figurative language. Participants described diverse emotional responses to the bereavement (e.g. sadness, anger, denial, acceptance), and the value of formal and informal bereavement support. Although many of the experiences described are accounted for in existing grief theory, some participants described a liminal experience not recognised within these theories. They felt trapped, unable to engage with loss or restoration, and unable to move forward as their planned future no longer existed. They sought out 'communitas' (solidarity in experiences), but often found support from their social networks had diminished. Metaphors were used to describe this liminality, with partner grief expressed as a dark agentic force, a monster, an abyss, and as water. The findings of this study offer original insights into experiences and trajectories of bereavement, and our understandings of prolonged or complicated grief. A novel model 'Between Loss and Restoration' is presented to include these experiences. Recognition of the place for liminality within the spectrum of grief experiences could enhance grief literacy and improve formal and informal bereavement support provision.

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.

I occasionally wear his huge sweaters… but I often prefer not to think about it: Bereaved children talking and not talking about parental loss

The unique perspective of children communicating about the loss of a parent has rarely been studied. In this qualitative research, we interviewed 12 children aged 7-12 and asked them about their experience communicating their loss. The children's verbal and non-verbal communication was characterized by constant movements away from and closer to various aspects of their loss, illustrated by three main themes: (a) children either talking about the loss or not talking about it; (b) first talking about the loss and then stopping to talk about it; and (c) simultaneously talking and not talking about the loss. Based on Stern's interpersonal relational thinking, our findings indicate that children wish to talk about the loss but also to avoid talking about it. The possibility of choosing to talk and not to talk with themselves and close individuals about the loss allows children to think about and articulate their feelings and thoughts.

Navigating the paradox: Strategies utilized by pregnant widows in an attempt to reconcile life and death

Losing a spouse is a traumatic experience, especially at a younger age. This experience is arguably more intense and complex if the woman becomes a widow while pregnant. In the current study, we examined the strategies Israeli women who became widows while pregnant utilized to reconcile life and death. Twelve adult women who became widows while pregnant participated in this study, which involved in-depth semi-structured interviews. A thematic analysis of the interview content revealed four main strategies utilized to reconcile their simultaneous paradoxical experience of both life and death: Passiveness - focusing on neither life nor death; Segregation - focusing on either life or death; Continuum - perceiving life and death are the same; and Integration - coming to terms with both life and death. The women commonly utilized multiple strategies while navigating this paradox, with most participants using all four at some point during their attempted reconciliation process.

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

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

"I never told my family I was grieving for my mom": The not-disclosing-grief experiences of parentally bereaved adolescents and young adults in Chinese families

In bereavement literature, the significance of open communication within the family is often highlighted. However, in recent years, scholars have noticed the complexity of grief communication in the family, especially challenges and obstacles to sharing grief. Our study seeks to contribute to the research by offering a deeper understanding of the grief-sharing experiences of parentally bereaved adolescents and young adults from China, a family-centered society with strong traditions of treating bereavement and grief as taboo. We used a narrative approach to analyze 82 interviews with 44 participants. We found that almost all the participants, regardless of their gender, parent's gender, cause of death, or time since loss, indicated that they never shared grief with other family members. Specifically, three themes emerged from the analysis. "Holding back tears during the funeral" reflects participants' struggle to protect the family (especially the surviving parent) through hiding their grief during the family crisis. "Pretending no grief at all after loss" shows how participants intentionally avoided any grief conversations within the family to not trigger others' grief. In addition, "Keeping grief secret as a family rule" indicates how Chinese families powerfully guided and influenced participants in avoiding the open expression of their grief. Our findings have drawn attention to the not-disclosing-grief experiences of bereaved adolescents and young adults in the Chinese context and the role of the family in it, therefore, calling for further support for bereaved young people, either within the family or through professional services.

Memorial playgrounds: Special ways of coping with extreme loss

The purpose of this study was to understand how active coping with extreme loss takes place when creating memorial playgrounds, as well as in relation to existing memorial playgrounds. Using qualitative methods and drawing from 63 cases, the research enriches our understanding of bereavement by revealing the central mechanisms through which active coping takes place and by presenting the distinct elements that the mechanisms are composed of. The study contributes to the research on bereavement by showing how active coping takes place both as an outcome of and during the memorial creation process.

Grandfathers' Experiences of Grief and Support Following Pregnancy Loss or Neonatal Death of a Grandchild

Pregnancy loss and neonatal death are recognized as distressing experiences for parents and other family members. However, no research has specifically addressed the experiences of grandfathers. This study aimed to understand grandfathers' grief experiences, and to identify supports they provide, receive, and desire following the loss of a grandchild in pregnancy or the neonatal period. Semi-structured interviews with 10 Australian grandfathers were analyzed, applying principles of thematic analysis. Three themes related to grief and three themes related to support were identified. Findings indicated that grandfathers expressed grief in a range of ways, and emotional expressiveness did not reflect the extent of their grief. Grandfathers typically provided extensive support to their child and family; however, few supports were available to help grandfathers. Recognition and validation of grandfathers' grief, early access to information, and guidance to a variety of supports including written materials, peer and professional support, is required.

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.

The role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief

Few studies examine the relationship of grief with interrelated and broad concepts. In this study, the role of sense of coherence and emotion regulation difficulties in the relationship between early maladaptive schemas and grief was investigated with individuals (N = 254) who have lost a close person in the last 5 years. Mediation and moderated mediation analyses revealed that individuals with early maladaptive schemas may experience more complicated grief symptoms through the effect of early maladaptive schemas. For individuals with self-sacrifice schema, difficulties in the grief process were regulated by moderate to high levels of sense of coherence.

Fostering the Reconstruction of Meaning Among the General Population During the COVID-19 Pandemic

The COVID-19 outbreak has seen people in many countries asked to radically modify their way of life in compliance with sweeping safety measures. During the current crisis, technology is turning out to be key, in that it allows practitioners to deliver psychological services to people who would otherwise be unreachable. However, professionals cannot solely rely on their traditional modes of practice, in that different methods are required to bring to light the needs of those affected by the emergency. People are being overwhelmed by a cascade of unusual and unexpected events that are putting a strain on their everyday routines and usual meaning-making systems; ongoing challenges to their employment and financial status will likely divert personal resources away from psychological well-being. We therefore argue that psychologists should also consider the needs of the general population. Among those who may require help-aside from the main targets of psychological intervention, such as healthcare personnel and COVID-19 patients and their relatives-specific attention should be paid to those who are not at the center of the crisis. We suggest that this large segment of potential users may benefit from a non-medical approach focused on the promotion of meaning-making processes. Indeed, the disruptive nature of the current situation hinders sense-making and threatens to undermine psychological balance and well-being, at an individual as well as at a societal level. The present article proposes a methodological perspective based on the reconstruction of meaning-making processes (sense of coherence, predictability, metaphors, narratives). Specifically, psychological interventions should promote personal and collective resources with a view to: "normalizing" current distressful experiences (i.e., acknowledging that such reactions are normal in light of the present situation); widening the observational field, taking relational contexts into account, and promoting an understanding of distressful experiences as coping strategies; fostering meaning-making/reconstruction processes through the use of appropriate metaphors and narratives; promoting a sense of coherence. We present two clinical vignettes to illustrate how these principles might be applied in practice. In conclusion, the exceptional psychological challenges posed by the COVID-19 pandemic require practitioners to adopt a broad and flexible perspective on clinical intervention.

Constructing stability - a classic grounded theory of next-of-kin in palliative cancer care

Background

Being next-of-kin to someone with cancer requiring palliative care involves a complex life situation. Changes in roles and relationships might occur and the next-of-kin thereby try to adapt by being involved in the ill person’s experiences and care even though they can feel unprepared for the care they are expected to provide. Therefore, the aim of this study was to develop a classic grounded theory of next-of-kin in palliative cancer care.

Method

Forty-two next-of-kin to persons with cancer in palliative phase or persons who had died from cancer were interviewed. Theoretical sampling was used during data collection. The data was analysed using classic Grounded Theory methodology to conceptualize patterns of human behaviour.

Results

Constructing stability emerged as the pattern of behaviour through which next-of-kin deal with their main concern; struggling with helplessness. This helplessness includes an involuntary waiting for the inevitable. The waiting causes sadness and frustration, which in turn increases the helplessness. The theory involves; Shielding, Acknowledging the reality, Going all in, Putting up boundaries, Asking for help, and Planning for the inescapable. These strategies can be used separately or simultaneously and they can also overlap each other. There are several conditions that may impact the theory Constructing stability, which strategies are used, and what the outcomes might be. Some conditions that emerged in this theory are time, personal finances, attitudes from extended family and friends and availability of healthcare resources.

Conclusions

The theory shows the complexities of being next-of-kin to someone receiving palliative care, while striving to construct stability. This theory can increase healthcare professionals’ awareness of how next-of-kin struggle with helplessness and thus generates insight into how to support them in this struggle.

Grief and coping of parents whose child has a constant life-threatening disability, hypoplastic left heart syndrome with reference to the Dual-Process Model

This paper reports on a study that examined the grief and coping of 29 parents whose child has hypoplastic left heart syndrome using the Dual Process Model. The study employed a secondary thematic analysis of interviews at key times of treatment and recovery for the child. After the diagnosis, parents experienced intense loss (LO), but focused upon restoration-orientated tasks (RO) to support their child. Over time, most parents employed a healthy oscillation between LO coping and RO coping, with waves of grief and with some grieving suppressed. There are some specific grief and coping and gender patterns employed by parents.

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.

Stories of trauma in family therapy with refugees: Supporting safe relational spaces of narration and silence

With the sharp increase of refugees' arrival and resettlement in western communities, adequate mental health care forms a pivotal dimension in host societies' responses to those individuals and communities seeking protection within their borders. Here, clinical literature shows a growing interest in the development of family therapy approaches with refugees, in which therapeutic practice engages with the pivotal role of refugee family dynamics in posttrauma reconstruction and adaptation in resettlement and aims at supporting posttrauma reconstruction through strengthening capacities to restore safety, meaning and connectedness within family relationships. In this article, we focus on the narrative restoration of meaning as central mode of posttrauma reparation and explore its specific dynamics and relational complexities in the context of therapeutic practice with refugee families. Hereto, we integrate theoretical and clinical scholarly work on trauma narration and its intersection with empirical findings on trauma communication in refugee families. Furthermore, we develop case reflections to illustrate different processes of engaging with trauma narration in refugee family therapy. This analysis develops an understanding of the multivoiced ways in which refugee families engage with traumatic suffering through different modes of expression that may entail both narration and silence and explores how family therapeutic practices can engage and mobilize voices of narration and silence as relational stories of restoration.

"We Hardly Ever Talk about It": Emotional Responsive Attunement in Couples after a Child's Death

Within Western cultural traditions, the idea that parents should talk about the death of their child with each other is deeply rooted. However, across bereaved parent couples there are wide variations in communication about their grief with each other. In this study, we explored the experiences of bereaved couples related to the process of talking and not talking. We used a thematic coding approach to analyze 20 interviews with 26 bereaved parents (11 interviewed as couples, four as individuals). Four main meanings emerged out of our analysis: not talking because of the inadequacy and pointlessness of words in grief, not talking as a way to regulate emotions in daily life, not talking as an expression of a personal, intimate process, and not talking because the partner has the same loss but a different grief process. In addition, we found that the process of talking and not talking can partly be understood as an emotional responsive process on an intrapersonal and interpersonal level. In this process partners search for a bearable distance from their own grief and their partner's, and attune with their relational context. A better understanding of this process is sought in a dialectical approach, emphasizing the value of both talking and not talking in a tense relationship with each other. Implications for clinical work are described.

Unraveling the Mobilization of Memory in Research With Refugees

In this article, we explore how narrative accounts of trauma are co-constructed through the interaction between researcher and participant. Using a narrative multiple-case study with Kurdish refugee families, we address how this process takes place, investigating how researcher and participants were engaged in relational, moral, collective, and sociopolitical dimensions of remembering, and how this led to the emergence of particular ethical questions. Case examples indicate that acknowledging the multilayered co-construction of remembering in the research relationship profoundly complicates existing deontological guidelines that predominantly emphasize the researcher's responsibility in sensitively dealing with participants' alleged autobiographical trauma narratives. Instead, our analysis invites qualitative researchers to engage in a continued, context-specific ethical reflection on the potential risks and benefits that are invoked in studies with survivors of collective violence.

Understanding How Bereaved Parents Cope With Their Grief to Inform the Services Provided to Them

Our objective was to develop a rich description of how parents experience their grief in the first year after the death of their child, and how various bereavement follow-up and support services helped them during this time, with the aim of informing follow-up and support services offered to bereaved parents. Our findings situated parents' individual experiences of coping within the social and institutional contexts in which they grieved. In the first year after the death of their child, parents regulated their intense feelings of grief through loss-oriented, restoration-oriented, and/or meaning reconstruction strategies. Often, parents' relationships with others and many of the bereavement follow-up and support services helped them in this regard. This article also explores how the results may aid service providers in accompanying parents in a way that optimizes outcomes for these parents.

A Synthesis of Coping Experiences After Infant Death

The purpose of this article was to synthesize qualitative research data that examine parental coping strategies following infant death. This qualitative synthesis found that parents who effectively cope with the death of their infant would continue the bond with the deceased child, have differences in the way they manage their emotions about the loss, and have intergenerational support in the form of family being present, acknowledging the death, performing immediate tasks, and providing helpful information. Nurses should be vigilant to ensure parents receive "memories" of their infant after an in-hospital death. Knowledge of the coping process can assist nurses and clinicians to better care and support parents following an infant death and, in turn, facilitate the healing process.

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.

When Baby Stops Breathing

Sudden unexplained infant death is responsible for 14% of Indiana’s infant mortality. The purpose of this qualitative research study was to describe mothers’ experiences when death of an infant occurred suddenly and unexpectedly. Field deputies or social workers interviewed mothers from central Indiana during the child-death team investigations. The Thematic Analysis Program from the Joanna Briggs Institute was used to analyze interview data. Sixteen de-identified interview cases were extracted, and a meta-aggregate method was conducted. The three synthesized themes were Extreme Emotional Shock, We Feel Like We’re to Blame, and Working Toward Moving On. Understanding these phenomena from mothers’ experience may assist in eliminating risks associated with infant deaths and inform nursing practice and policy.

Disenfranchised grief following African American Homicide loss: an inductive case study

Disenfranchised grief is experienced when a mourner's grief response is socially invalidated, unacknowledged, or discouraged. When the circumstances of death or the emotional reactions of the griever violate social norms, empathic failures can occur within the bereaved individual's support systems. This study used conventional content analysis, an intensive and inductive qualitative research method, to analyze the experience of one African American woman who lost her only son to homicide, a particularly distressing and marginalized form of loss. Results elucidate both the empathic failings and resiliencies within the social systems of this griever and emerged from the perspectives offered by the bereaved mother and her primary supporter. Clinical implications and suggestions for future research are discussed.

Dyadic coping of parents after the death of a child

This article explores the grief process of parents following the death of a child due to a life-limiting illness, putting particular focus on dyadic coping. Participants included 46 married parents (23 couples). A mixed-methods design was used with in-depth interviews and standardized questionnaires. All parents were interviewed separately. Aspects of common dyadic coping (e.g., sharing emotions or maintaining bonds to the child) helped them work through their grief as a couple but also individually. The authors conclude that dyadic coping plays an important role in grief work and adjustment to bereavement.

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.

Methodology or method? A critical review of qualitative case study reports

Despite on-going debate about credibility, and reported limitations in comparison to other approaches, case study is an increasingly popular approach among qualitative researchers. We critically analysed the methodological descriptions of published case studies. Three high-impact qualitative methods journals were searched to locate case studies published in the past 5 years; 34 were selected for analysis. Articles were categorized as health and health services (n=12), social sciences and anthropology (n=7), or methods (n=15) case studies. The articles were reviewed using an adapted version of established criteria to determine whether adequate methodological justification was present, and if study aims, methods, and reported findings were consistent with a qualitative case study approach. Findings were grouped into five themes outlining key methodological issues: case study methodology or method, case of something particular and case selection, contextually bound case study, researcher and case interactions and triangulation, and study design inconsistent with methodology reported. Improved reporting of case studies by qualitative researchers will advance the methodology for the benefit of researchers and practitioners.