Suicide Bereavement and Complicated Grief: Experiential Avoidance as a Mediating Mechanism

In the wake of increased interest in the specific features of suicide bereavement, the current study examines (a) the association between suicide bereavement and complicated grief and (b) the mediating effect of experiential avoidance on the association between suicide bereavement and complicated grief. The tests revealed a significant indirect effect of suicide bereavement on complicated grief through experiential avoidance. This finding suggests that traumatic characteristics of suicide bereavement may inhibit the grieving process by increasing experiential avoidance and emphasizing a cognitive approach for complicated grief of people who have lost their loved one to death by suicide.     

Divergent and Convergent Validation of the Complicated Grief Prototype Narrative

Although there is a prototype narrative for complicated grief (CG), there are neither divergent nor convergent validity studies of its clinical value. We evaluated the CG prototype narrative using a sociodemographic questionnaire and the Clinical Interview for Complicated Grief Diagnosis. We first conducted a convergent validation analysis followed by a divergent validation analysis. Results showed that participants with CG identified significantly more with the complicated grief prototype narrative than participants without CG.     

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.     

Yearning and Its Measurement in Complicated Grief

Persistent intense yearning for the deceased is a core clinical feature of complicated grief (CG) that distinguishes it from other mental disorders that develop following loss. The Yearning in Situations of Loss Scale (YSL) is a recently developed assessment of yearning. To assess the psychometric properties of the YSL in those with CG, we administered the YSL, Inventory of Complicated Grief, and Quick Inventory of Depression Symptomatology to 303 treatment-seeking bereaved adults with CG. Our results suggest the YSL is a reliable assessment with acceptable convergent and discriminant validity as a measure of yearning in those with CG.     

Circumstances of Death and Complicated Grief: Indirect Associations Through Meaning Made of Loss

Losses by violent means and the loss of primary attachment figures may increase the likelihood of developing a chronic and severe grief response (referred to as complicated grief, or CG). Path analysis was used to examine the relationships between these risk factors and CG symptoms. College student participants filled out online questionnaires relating to their bereavement. Analyses provided support for statistical models whereby meaning made of the loss fully mediated the association between cause of death and CG symptoms and partially mediated the association between relationship to the deceased and CG symptoms. Although based on cross-sectional data, these findings provide additional support for meaning-oriented understandings of adaptation to loss.     

Complicated Grief: An Evolving Theoretical Landscape

The bereavement literature has proliferated in recent decades, generating a shift from conceptualizing grief as a stepwise, uniform process to an idiosyncratic experience that varies among individuals. Among the most notable developments is the empirical exploration of complicated grief—a protracted, debilitating, sometimes life‐threatening response to the death of a loved one—and the testing of novel interventions to treat it. This article provides counselors with recommendations for identifying and treating complicated grief.     

Impaired autobiographical memory in complicated grief

This study investigated the relationship between autobiographical memory and goals in complicated grief (CG). Twenty-four individuals with CG and 21 bereaved individuals without CG completed an autobiographical memory task and a personal goals task. CG participants were more likely to recall memories related to their loss, particularly in response to negative cues. There was a positive relationship between the proportion of loss-related memories recalled and the proportion of grief-related goals held by individuals after controlling for symptom level. Individuals with CG also showed impaired retrieval of specific autobiographical memories in response to both positive and negative cues. These results suggest that CG is characterised by impaired and biased retrieval of specific autobiographical memories. These patterns are consistent with propositions stemming from the self-memory models of autobiographical memory.     

Complicated Grief in Canada: Exploring the Client and Professional Landscape

Complicated grief (CG) is one of the central themes in bereavement research and advanced clinical practice today. Using a mixed-methods approach, we wanted to learn (a) what tools Canadian practitioners used to identify or diagnose CG and (b) what interventions or strategies they used to address CG. Sixty-three professionals responded to our survey. There were no straightforward answers to these questions: the state-of-the art of CG in Canada is, in fact, complicated. Practitioners used a wide assortment of tools and strategies with no consensus on any one approach or tool. Building a Canadian CG community of practice was recommended.     

Suicidal Ideation in Elderly Bereaved: The Role of Complicated Grief

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.     

Intimacy and Complicated Grief among Chinese Elders Having Lost their Spouses: Mediating Role of Meaning Making

This study aims to investigate the mediating role of meaning making in the relationship between intimacy and complicated grief among bereaved elders. A sample of 352 bereaved elders in rural China participated in the study. Both the linear and quadratic effects of meaning making illustrated a model that mediated the effect of intimacy on complicated grief. Essentially, findings revealed that only high levels of meaning making predicted low levels of complicated grief. This study thereby supplements existing research about meaning-making theory.     

A Sense of ‘unrealness’ about the death of a loved‐one: An exploratory study of its role in emotional complications among bereaved individuals

After a loss, some people develop complicated grief (CG) and depression. A recent cognitive‐behavioural model postulates that three processes account for such problems: (a) lack of integration of the loss with implicit autobiographical knowledge about the relationship with the lost person, (b) negative cognitions and (c) avoidance behaviours. In the current study, it was proposed that the ‘lack of integration of the loss’ is mainly an implicit process, but has an explicit, introspectively accessible counterpart in the form of ‘a sense of unrealness’ that can be defined as a subjective sense of uncertainty or ambivalence about the irreversibility of the separation. The role of this ‘sense of unrealness’ was studied using self‐reported data from 397 mourners. Among other things, findings showed that items constituting unrealness were distinct from those of CG and depression. In addition, unrealness was significantly associated with CG, when controlling for negative cognitions, avoidance and concomitant depression. Copyright © 2009 John Wiley & Sons, Ltd.     

Negative cognitions and avoidance in emotional problems after bereavement: a prospective study

Cognitive behavioural conceptualisations of grief propose that negative cognitions and avoidance strategies play a key role in emotional problems after bereavement. In the current study, this assumption was examined. Ninety-seven individuals who had lost a relative less than 5 months ago completed questionnaires tapping background and loss-related variables, negative cognitions (about the self, life, the future, and one's own grief reactions), avoidance, and symptoms of complicated grief (CG) and depression. Of these mourners, 70 people (72%) completed symptom measures again 6 months later at T2 (7-10 months after the loss), and 60 (62%) completed symptoms measures still 9 months later at T3 (16-19 months after the loss). Among other things, results showed that all four cognitive variables and the avoidance variable were strongly associated with concurrent and prospective symptom levels, even when the influence of relevant background/loss-related variables was controlled. In addition, independent of initial symptom levels, most of the cognitive variables predicted later CG and depression. The avoidance variable only predicted additional variance in depression at T3 beyond T1 symptom levels. Findings indicate that negative cognitions are important in emotional problems after bereavement and that the role of avoidance in the development of these problems needs further scrutiny.     

Pastoral Theological Reflection on Grief: Contemporary Theory and the Practice of Ministry by Melissa Kelley

This article highlights four of Melissa Kelley’s contributions in her book Grief: Contemporary Theory and Practice. The author identifies these as: 1) Kelley’s capacity to distill and synthesize the most important areas of contemporary grief theory; 2) her work on attachment theory and its relationship to people’s ways of coping with grief; 3) the focus on the research of Bonanno et al. (Journal of Gerontology Series B: Psychological Sciences and Social Sciences 60:67–73, 2005) and showing us who is most vulnerable and in need of pastoral care during grief; 4) her emphasis on meaning making as the core of the grieving process. The article also lifts up questions concerning communal practices for grieving loss born of injustice and the need for prevention and fostering coping mechanisms so that the worst effects of grief might be mitigated.     

Development and Preliminary Evaluation of a Cognitive-Behavioral Intervention for Perinatal Grief

Perinatal loss, typically defined as fetal death beyond 20 weeks gestation through infant death 1-month postpartum, is a potentially traumatizing experience for parents occurring in approximately 1% of births in the United States. Although many women recover, 15% to 25% have enduring grief-related symptomatology and functional impairment. Perinatal grief is a unique bereavement experience, but clinical resources for detecting and treating severe perinatal grief are rare and interventions are largely without empirical support. We developed and pilot tested a cognitive-behavioral intervention targeting the psychological and behavioral sequelae of perinatal bereavement. To initially evaluate the feasibility and efficacy of the intervention, 5 women who suffered a perinatal loss were randomized to a 2-week, 4-week, or 6-week baseline period in a multiple-baseline single-case experimental design. In most cases, after the respective baseline periods, there was a steady decline in reported grief symptoms. These gains were largely maintained at a 6-week follow-up assessment. This study provides initial evidence in support of future research and clinical efforts tailoring cognitive behavioral interventions to meet the specific needs of women who experience perinatal loss.     

Self-defining memories in complicated grief

There is increasing attention to the mechanisms underpinning maladaptive responses to bereavement. This study indexed self-defining memories in bereaved individuals with and without complicated grief (CG). Participants with and without complicated grief (N = 40) were asked to describe three self-defining memories. Results showed that CG participants provided more self-defining memories involving the deceased. Both groups were equally likely to report their loved one's death as a self-defining moment, however, the no-CG group showed more evidence of benefit finding in their memory narratives and experienced less negative emotion on recall. The findings suggest that CG is associated with distinctive patterns of autobiographical memory that are linked to self-identity. The pattern is consistent with self-memory system models of autobiographical remembering, and suggests that grieving individuals who experience ongoing yearning for their loved one view their self-identity as more closely linked to the deceased are more distressed by memories involving the loss.     

Elegiac Poetry: A Pastoral Resource with Complicated Grief

This essay argues that elegiac poetry, the poetry of mourning, may be a resource for pastoral care with complicated grief. It builds on Freuds distinction between mourning (normal grief) and melancholia (complicated grief), particularly as appropriated by French literary critic and psychoanalyst Julia Kristeva. It makes the case for elegy as a locus for externalizing a lost object which, in complicated grief, has been internalized as part of the bereaved persons self and which is not only grieved but also treated ambivalently if it is not hated. Drawing on the suffering God motif in Christian theologies of the cross, theological reflections supplement psychological arguments.     

Field Trial of a Complicated Grief Psychosocial Program for Adolescents in Occupied Palestine

The current study evaluated the new “Children and Grief” program for Palestinian adolescents (n = 158), aged 10–18, referred to counselors for complicated grief. A mixed methods quasi-experimental design involved non-randomized intervention group (n = 79), waitlist (n = 79), and measures of program fidelity and cost. Traumatic loss was identified from case files. Standardized measures assessed complicated grief, posttraumatic stress, and depression at pre and post-test. Interviews of 9 adolescents and 9 presenters explored subjective experience of program delivery. Analysis involved multivariate analysis of variance (MANOVA) and quasi-qualitative analysis of interviews. A large effect size was found for reduced complicated grief. Randomized control trials, longitudinal research, and studies that explore the impact of martyrdom on coping with grief are needed.     

Traumatische Trauer – ein eigenständiges Krankheitsbild?

Grief is a highly individualized process influenced by intrapsychic, interpersonal and social factors. The definition of normal and pathological grief is complicated by the variety of grief reactions. Empirical research indicates that pathological grief may be concerned considered as a separate entity. Two research groups developed empirically validated criteria with a special focus on the traumatic aspect of grief. The current state of research allows, however, in our opinion not the conclusion, that the proposed diagnostic criteria for complicated (Horowitz et al. 1997) or traumatic grief (Prigerson et al. 1999b) do not enclose all types of grief. Further empirical research on representative samples is necessary to validate previous findings and to differentiate specific subgroups of pathological grief.     

Levels of specificity of autobiographical memories and of biographical memories of the deceased in bereaved individuals with and without complicated grief

Traumatized individuals experiencing posttraumatic stress have difficulty retrieving specific autobiographical memories to cue words on the Autobiographical Memory Test (AMT; J. M. G. Williams & K. Broadbent, 1986). This may represent a generalized, functional avoidance of the personal past. However, such individuals also often report specific intrusive memories of their trauma in the day-to-day. This raises the possibility that memories tied to the source of the person's distress are immune to this putative avoidance process. This was investigated in bereaved individuals with complicated grief (CG) who reported intrusive, specific memories from the life of their deceased loved one, and matched bereaved controls without CG. Participants performed the AMT and two Biographical Memory Tests (BMTs), cueing memories from the life of the deceased (BMT-Deceased) and from a living significant other (BMT-Living). To negative word cues, the CG group showed reduced specificity for the AMT and BMT-Living, relative to controls, but this effect was reversed on the BMT-Deceased. These data support the proposal that memories tied to the source of an individual's distress are immune to the processes that underlie the standard reduced specificity effect.