Risk Factors For Complicated Grief Research Articles

Music therapy for supporting informal carers of adults with life-threatening illness pre- and post-bereavement; a mixed-methods systematic review

BackgroundMusic therapy interventions with informal carers of individuals with life-threatening illness at pre- and post-bereavement is an increasingly important clinical area. This systematic review is the first to synthesise and critically evaluate the international evidence associated with music therapy with adult informal carers pre- and post-bereavement. Specifically, the objectives were: i) to describe the characteristics and effectiveness of music therapy interventions which aim to improve health-related outcomes for adult informal carers of adults with life-threatening illness (pre- and post-bereavement), and ii) to describe the experience of music therapy for adult informal carers of adults with life-threatening illness (pre- and post-bereavement).MethodsEligibility: adult informal carers of adults at end of life or bereaved; music therapy interventions for improving health-related outcomes; qualitative; mixed-method; and quantitative studies including comparators of any other intervention; published in English from 1998 onwards. Six databases were searched up to July 2022. A JBI mixed-methods systematic review approach was followed throughout, including quality appraisal, data extraction and a convergent segregated approach to synthesis and integration.ResultsA total of 34 studies were included, published between 2003 and 2022. Most were conducted in North America (n = 13), Australia (n = 10), or Europe (n = 8). No studies were conducted in low- and middle-income countries or in the UK. The majority were qualitative (n = 17), followed by quasi-experimental (n = 8), mixed-methods (n = 7) and two RCTs. The majority focused on carers of individuals with dementia (n = 21) or advanced cancer (n = 7). Seventeen studies were purely quantitative or included a quantitative component. During meta-synthesis, findings were aligned to core outcomes for evaluating bereavement interventions in palliative care and previously identified risk factors for complicated grief. Commonly targeted outcomes in quantitative studies included quality of life and mental wellbeing, showing equivocal effectiveness of music therapy with significant and non-significant results. Twenty-two studies either purely qualitative or with a qualitative component underwent meta synthesis and suggested a diverse range of improved pre- and post-bereavement outcomes for informal carers across all core outcomes, and across all risk and protective factors, including psychological, spiritual, emotional, and social outcomes.ConclusionsQualitative studies provide moderate to strong evidence for improved health-related outcomes for adult informal carers of adults with life-threatening illness pre-bereavement. Limited studies including those bereaved negates conclusions for the bereavement phase. Comparisons and explanations for effectiveness across quantitative and qualitative studies are equivocal, with a high risk of bias and small samples in the limited number of quantitative studies, demonstrating a need for high-quality RCTs.Systematic review pre-registrationPROSPERO [CRD42021244859].

Complicated Grief During COVID-19

Abstract. Cultures across the globe have evolved time-tested rituals to honor those who die and offer solace and support to survivors with the goal of helping them to accept the reality of the death, cope with the feelings of loss, adjust to life without the deceased, and find ways to maintain a connection to the memory of the deceased. The COVID-19 pandemic has disrupted these rituals and brought significant changes to the way we mourn. Specifically, public health responses to COVID-19 such as social distancing or isolation, delays or cancellations of traditional religious and cultural rituals, and shifts from in-person to online ceremonies have disrupted rituals and thus made it more difficult to access support and complete the psychological tasks typically associated with bereavement. This paper conceptualizes the common bereavement tasks including emotion-focused coping, maintaining a connection to the deceased, disengagement and reframing death and loss, and problem-focused coping. It provides examples of how the COVID-19 pandemic has altered mourning rituals across several cultures and religions and contributed to prolonged grief disorder as defined by the ICD-11 that includes depressive symptoms and post-traumatic stress. Early evidence suggested that the suddenness of loss, the social isolation, and the lack of social support often associated with COVID-19-related death are salient risk factors for complicated grief. As a consequence, psychological assessments, grief counseling, and mental health support are needed by families of patients who died from COVID-19. These services must be essential components of any comprehensive public health response to the pandemic.

Knowledge Level of Health Care Providers about Complicated Grief during the COVID-19 Pandemic.

Objective: The coronavirus 2019 (COVID -19) pandemic had great psychological impact on COVID-19 patients and their families. Relatives of the deceased COVID-19 patients are at risk for complicated grief. Healthcare providers (HCPs) should be able to identify complicated grief cases. The aim of this study was to assess HCP knowledge regarding complicated grief during the COVID-19 pandemic. Method : This cross-sectional study was conducted using an online researcher-made questionnaire. The questionnaire was designed and validated before being used in this study. The questionnaire included demographic questions as well as knowledge about complicated grief and its symptoms, risk factors and management. The link to the questionnaire website was sent to HCP governmental and private sectors. Data was analyzed using the ordinal regression model by the SPSS 16 software. Results: A total of 887 HCPs (69% female and 31% male) participated in this study. Majority of the participants (594, 70%) had fair overall knowledge about complicated grief while 206 (23.2%) participants had poor knowledge. Poor knowledge level about risk factors for complicated grief was observed in 44.3% of the participants. Fair or poor knowledge about prevention and management of complicate grief was observed in 39.2% of participants. Knowledge about complicated grief had a significant positive relationship with female gender (OR: 1.55; 95% CI: 1.15-2.08) and higher education level (OR: 1.86; 95% CI: 1.37-2.54). Conclusion: Knowledge of HCPs about complicated grief was low. There is need for HCP knowledge improvement regarding complicated grief by appropriate education.

Risk factors for complicated grief among family members bereaved in intensive care unit settings: A systematic review.

BackgroundFamilies of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.Materials and methodsMEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.ResultsSeven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.ConclusionThis systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503)

Complicated Grief, Depression, Health and Attachment Style in First Degree Relatives of Individuals with a Chronic Psychotic Disorders.

Complicated grief (CG) is a form of unrelenting grief after the death of a loved one. However, family members of individuals who suffer from Schizophrenia, Schizoaffective disorders and Bipolar disorder may experience symptoms of CG even though their loved one is still alive. The present study assessed CG and risk factors for CG in first degree relatives of individuals with severe chronic mental illness. The incidence of CG was examined in 78 parents, siblings, adult children and spouses recruited through organizations and social media that provide support services for individuals suffering from mental illness and their families. High rates of CG (39.7%) were found in this group. CG was associated with a higher prevalence of posttraumatic and depression symptoms and poorer physical health. These findings may contribute to heightening therapists' awareness of the importance of assessing, acknowledging and resolving CG in the family members of patients with chronic psychotic disorders.

Risk Factors for Complicated Grief in the Military Community.

Death, grief, and loss have always been a part of the military community. Historically, research on grief in the military has focused on the impact of combat operations and deployment separations on the grief experience of service members and loved ones. However, as the transient nature of military life and the dangers of military service exist outside of combat operations and military deployments, it is important to examine how grief may impact the military community in times of peace as well as war. The purpose of this commentary is to discuss the components of the military community that place its members at a higher risk of experiencing complicated grief.

Rapid implementation of a support intervention for bereavement at the beginning of the COVID-19 pandemic

IntroductionThere have been over 900,000 deaths from COVID-19, with more than 3 million people bereaved. These deaths are associated with factors leading to poor bereavement outcomes, and distress in frontline-staffObjectivesto (i)present the rapid implementation of an intervention for bereavement support; (ii)characterize first calls and follow-up.MethodsWe recruited a multidisciplinary team and prepared a structure called “SIB” (Support and Intervention for Bereavement) in a matter of days. There were three steps for the support (Screening, First-line intervention, Second-line intervention (short follow-up). We collected data screening risk factors for complicated grief (CG).ResultsBetween March 24th-May 14th (lockdown, March 16th-May 13th), the hotline received nineteen calls for an intervention. The hospital contacts were various, including mortuary. Fifteen relatives were followed, among them thirteen bereaved for ten deaths (on 52 deaths=19.23%). Dead persons were young (m=59.68 years-old, SD=15.25). All contacts reported several risk factors for a CG (no “goodbye” (100%), no funeral rituals (82.35%)). Six relatives were addressed for short follow-up.ConclusionsThe actual pandemic is at high risk for complicated grief and may until 2021. We hope that all hospitals would implement basic bereavement outreach programs to prepare families for the death and to support them afterwards, as well as provide basic support to frontline staff.DisclosureNo significant relationships.

It's Complicated-Adolescent Grief in the Time of Covid-19.

Presently, there is a real possibility of a second pandemic occurring: a grief pandemic. There are estimated to be over 1 million children and young people experiencing bereavement because of Covid-19. Adolescent grief is unique due to bio-psycho-social factors such as increased risk-taking, identity-formation, and limited capacity for emotional regulation. In this article, we will argue that adolescents are at increased risk of developing complicated grief during the Covid-19 pandemic, and that it is vital that services are improved to recognize and address this need before secondary problems emerge, including anxiety, depression, and substance abuse. Complicated grief in adolescents is widely underrecognized and often misdiagnosed as a range of mental health problems, addictions, and offending behavior. For example, 25% of <20 year olds who commit suicide have experienced childhood bereavement, whilst 41% of youth offenders have experienced childhood bereavement; this is in comparison with only 4% of the general population. Many of the broader risk factors for complicated grief were already increasing prior to the Covid-19 pandemic, including increased loneliness amongst young people, and the collapse of collective structures to help people manage grief. We propose that this pandemic could be a catalyst for mental health professionals to support and nurture the caring communities emerging in this time as an essential resource to prevent the onset of a grief pandemic.

Bereavement and reactions of grief among children and adolescents: Present data and perspectives

Losing a loved one is among the most common and stressful traumatic events that a child or and adolescent can experience and can be associated with mental health and somatic disorders, as well as a range of life issues and potentially negative outcomes that may impact longitudinal development. Complicated grief, a disorder that has been studied primarily among adults, has received increasing recognition among children and adolescents in recent years. The demonstration of the distinctive character of grief reactions in relation to major depressive disorder and posttraumatic stress disorder has resulted in the inclusion of “persistent complex bereavement disorder” in an annex section of DSM-5 and of “prolonged grief disorder” in ICD-11. The grieving process in children and adolescents is not linear and is often characterised by periods of regression. Developmental phases should be taken into account to understand and clinically describe grief reactions occurring during childhood and adolescence. There are currently numerous interventions for bereaved children and adolescents, but little evidence to support them. More research focusing on the understanding of the underlying mechanisms and the risk factors for complicated grief among children and adolescents, as well as the implementation of evidence-based interventions, is definitely warranted.

Bereavement in critical care: A narrative review and practice exploration of current provision of support services and future challenges.

This special article outlines the background to bereavement in critical care and scopes the current provision and evidence for bereavement support following death in critical care. Co-authored by a family member and former critical care patient, we aim to draw out the current challenges and think about how and where support can be implemented along the bereavement pathway. We draw on the literature to examine different trajectories of dying in critical care and explore how these might impact bereavement, highlighting important points and risk factors for complicated grief. We present graphic representation of the critical junctures for bereavement in critical care. Adjustment disorders around grief are explored and the consequences for families, including the existing evidence base. Finally, we propose new areas for research in this field.

Associations between self-compassion and complicated grief symptoms in bereaved individuals: An exploratory study

Grief is a normal and natural response to the loss of a loved one that is characterized by a broad range of emotional, behavioral, cognitive, and physiological symptoms. For most bereaved, these symptoms abate over time as the individual comes to terms with the loss. However, about 10% of the bereaved experience a persistent and debilitating grief reaction, a condition that has been termed complicated grief or prolonged grief. Self-compassion has been defined as a kind and caring attitude towards oneself when experiencing suffering. The present study explored the associations between self-compassion and complicated grief symptoms in a bereaved sample from the general population. Participants completed measures of complicated grief (Inventory of Complicated Grief), self-compassion (Self-Compassion Scale), and neuroticism (NEO FFI-3 neuroticism scale). In line with previous studies, bereavement by unexpected death and high neuroticism were related to grief symptom severity. The results further showed statistically significant relationships between low self-compassion and the severity of complicated grief symptoms. No associations between the cause of death (natural expected, natural sudden, or unnatural) and self-compassion were found. The self-kindness component of self-compassion did not moderate the relationships between established risk factors for complicated grief (cause of death and neuroticism) and complicated grief symptomatology. It is concluded that it is important for clinicians to be attentive to the role that low self-compassion may have in the grief response of bereaved individuals.

Diagnosis of Complicated Grief Using the Texas Revised Inventory of Grief, Brazilian Portuguese Version

Background: Complicated grief is characterized by persistent yearning for the deceased, intense sorrow and emotional pain in response to death causing significant distress. Complicated grief is often under recognized and undertreated. The Texas Revised Inventory of Grief (TRIG) is a questionnaire that has been demonstrated to have high validity and reliability in the assessment of grief. Our objective was to translate, adapt, and validate the TRIG to Brazilian Portuguese and to verify whether the TRIG, in a bereaved population, is able to distinguish between those with and those without complicated grief and to identify which elements in the scale contribute to this. Methods: Two stages: a) cross-culture adaptation of a questionnaire, and b) cross-sectional study of reliability and validity. Setting and Participants: 165 adult patients were recruited from a) the Grief Outpatient Clinic at the Department and Institute of Psychiatry - University of Sao Paulo, b) private practice at the same department, and c) co-workers who have lost a loved one. All the patients were interviewed with the TRIG. According to clinical criteria69 of 165 bereaved patients were presenting complicated grief. Results: Cross-culture adaptation: the TRIG was translated from American English, then back-translated and finally compared with the Brazilian Portuguese version by two bilingual psychiatrists. Reliability: the Cronbach’s alpha coefficients (internal consistency) of the TRIG scales were 0,735 (part I) and 0,896 (part II). Sensitivity, specificity as well as cutoff points to identify complicated and noncomplicated grief, were measured using the ROC curve. Using the total score of 104 (part I + part II + Part III + psychographics variables), we can correctly classify 71.3% of individuals with and without complicated grief. The construct validity was assessed by factor analysis and confirmatory analysis. Furthermore, by logistic regression, our study demonstrated that a low education level, age of the deceased and age of the bereaved, loss of a son or daughter, and unexpected death were all risk factors for complicated grief. Our results also suggest that religion may influence complicated grief. Conclusion: The TRIG adapted to Brazilian Portuguese is as reliable and valid as the original version. In the evaluation of Brazilian bereaved, it was able to distinguish individuals with and without complicated grief. And, we suggest a cut-off value of 104 for complicated grief.

Prevalence and risk factors of complicated grief among Sichuan earthquake survivors

BackgroundDisasters usually involves massive casualties, yet few post-disaster studies explore the prevalence of complicated grief (CG) among survivors. Complicated grief is a distinct psychological disorder, and is associated with impaired physical and psychological functions. Given such gap in the literature and the significance of this topic, this study is hoped to offer more information of complicated grief among survivors who lost their loved ones in disaster. Adopting a large scale survey, the prevalence and risk factors of CG among bereaved survivors one year after the Sichuan earthquake in China were explored. MethodsIn total 803 bereaved survivors participated the study by filling a questionnaire on measuring CG symptoms, posttraumatic stress disorder (PTSD) symptoms, intrapersonal factors, earthquake related factors, bereavement related factors, and an interpersonal factor. ResultsThere were 71.1% of the participants scored higher than the cutoff point of CG symptoms. Close relationship with the deceased, PTSD symptoms, losing means of livelihood, physical injury, and terrifying experience in the earthquake, were identified to be risk factors for CG. LimitationsThe study was cross-sectional and the data was collected through a self-reported questionnaire. The sample was recruited from one of the most severely affected counties, thus the generalizability of the results should be interpreted with caution. ConclusionsA large portion of bereaved earthquake survivors suffered from CG symptoms one year after the disaster. Risk factors found in this study can be used to identify high risk groups, who need special care, support, and bereavement interventions.

Risk factors for complicated grief in older adults.

Older adults grieving the death of a spouse have been found to have a higher risk of complicated grief compared with younger adults. The study objective was to find out whether personal characteristics of the patient and the bereaved partner, or characteristics of the patient's illness, end-of-life care, and the nature of death are risk factors for complicated grief in older adults. We performed a nested case-control study within the Rotterdam Study. We selected 100 couples of which one person had deceased and the other person experienced "complicated grief," and 100 control couples of which one person had deceased and the other person experienced "normal grief." Complicated grief was assessed with a 17-item Inventory of Complicated Grief (ICG). Determinants were assessed using several sources of information that were available for all participants of the Rotterdam Study. Additionally, medical files of the deceased were manually screened. Logistic regression analysis was performed. Only depression at baseline was significantly associated with complicated grief. Bereaved partners with depression at baseline had a higher risk of complicated grief compared to bereaved partners without depression (OR=3.48; 95% CI=1.40-8.68). Our results suggest that complicated grief in older adults is not clearly related to the circumstances of dying of the deceased partner. Preexisting conditions such as depression seem to be more important in explaining the occurrence of complicated grief.

Cognition, structural brain changes and complicated grief. A population-based study.

Several psychosocial risk factors for complicated grief have been described. However, the association of complicated grief with cognitive and biological risk factors is unclear. The present study examined whether complicated grief and normal grief are related to cognitive performance or structural brain volumes in a large population-based study. The present research comprised cross-sectional analyses embedded in the Rotterdam Study. The study included 5501 non-demented persons. Participants were classified as experiencing no grief (n = 4731), normal grief (n = 615) or complicated grief (n = 155) as assessed with the Inventory of Complicated Grief. All persons underwent cognitive testing (Mini-Mental State Examination, Letter-Digit Substitution Test, Stroop Test, Word Fluency Task, word learning test - immediate and delayed recall), and magnetic resonance imaging to measure general brain parameters (white matter, gray matter), and white matter lesions. Total brain volume was defined as the sum of gray matter plus normal white matter and white matter lesion volume. Persons with depressive disorders were excluded and analyses were adjusted for depressive symptoms. Compared with no-grief participants, participants with complicated grief had lower scores for the Letter-Digit Substitution Test [Z-score -0.16 v. 0.04, 95% confidence interval (CI) -0.36 to -0.04, p = 0.01] and Word Fluency Task (Z-score -0.15 v. 0.03, 95% CI -0.35 to -0.02, p = 0.02) and smaller total volumes of brain matter (933.53 ml v. 952.42 ml, 95% CI -37.6 to -0.10, p = 0.04). Participants with complicated grief performed poorly in cognitive tests and had a smaller total brain volume. Although the effect sizes were small, these findings suggest that there may be a neurological correlate of complicated grief, but not of normal grief, in the general population.

Prevalence of Complicated Grief and Posttraumatic Stress Disorder in Children and Adolescents Following Sibling Death

The effects of complicated grief (CG) in children and adolescents following the death of a sibling have not been studied in depth until recently. Research indicates that siblings and families are affected in a variety of ways by an ever-increasing number of factors. Risk factors for CG include, but are not limited to, coping strategies of the parents, the number of years since the death, the type of death, family support systems and relationships, therapeutic interventions, developmental ages of the siblings at the time of death, and the idea of finding meaning in life following the death. A death by accident or suicide which provides little or no warning to the family can cause a significant impact on families as compared to a death due to chronic illness. CG resulting in the development of anxiety disorders and symptoms of posttraumatic stress disorder (PTSD) may arise if one or all of these risk factors are present. This article will present an overview of studies related to the development of CG and PTSD in children and adolescents following death of a sibling, factors that may precipitate development of symptomatology, and recommendations for therapeutic interventions and future studies.

Risk factors for complicated grief (CG) and utilization of a hospice bereavement program.

e19588 Background: The Medicare hospice benefit mandates that bereavement services be provided to a surviving caregiver for a period of one year following a patient’s (pt) death. Identifying caregivers at risk for CG is essential so that appropriate interventions can be provided. Methods: Our objective was to identify specific features predicting for CG in surviving caregivers of pts with a malignancy enrolled in an academic based hospice program and determine utilization of Medicare’s bereavement services. Hospice charts for 65 patients whose caregivers were consecutively discharged from bereavement follow-up between January 2009 and December 2011 were reviewed. Assessments for CG features were performed with use of chaplain and social worker visits, and phone calls from a trained bereavement volunteer to caregivers at 6-8 wks and 6 months after a pt’s death. A discharge assessment was completed at 13 months. Results: Fifty (77%) hospice pts had a cancer (ca) diagnosis and tended to have a shorter average length of hospice enrollment than non-ca pts (34 vs 60 days, p=0.11). There was no difference in risk of caregiver CG between ca vs non-ca diagnoses (p=0.12). Twenty-one (42%) of ca pt caregivers were identified at risk for CG. Ca pts ≤ 50 yrs at the time of hospice enrollment were more likely to have caregivers identified at risk for CG compared to those ≥ 50 yrs (3, 100% vs 18, 38%, p=0.07). At risk ca caregivers had a lower average pt age at time of hospice enrollment than lower risk caregivers (mean pt age 67 vs 76 yrs, p=0.03). Eight ca caregivers (38%) identified at risk for CG received intensive bereavement counseling; 13 (62%) subsequently received routine bereavement follow up; none were lost to follow up. Length of enrollment, caregiver employment status and caregiver relationship did not predict for risk of CG. No ca caregivers required intensive bereavement services beyond 12 months post pt death. Conclusions: Young patient age at time of hospice enrollment is associated with an increased risk of caregiver CG.Intensive bereavement counseling was required by 38% of ca caregivers, and none required &gt;1 yr of service. Further study needs to be done to see if caregivers are receiving adequate bereavement support through the hospice benefit.

Análisis del duelo en una muestra de familiares de pacientes ingresados en una unidad de cuidados paliativos

ObjectiveRelatives of patients admitted to a Palliative Care Unit (PCU) are at high risk for many distressing symptoms. Our aim is to describe the intervention done with the bereaved families of patients who died in a PCU, analyzing the psychological support needs detected and the clinical team's answers. Material and MethodsDescriptive prospective study was carried out during one year (February 2009-February 2010) based on telephone interviews with families of patients who had died in the PCU. One month after death, the psychologist makes a first semi-structured interview with the main carer, to assess emotional situation and identify risk factors for complicated grief. Psychological intervention is arranged according to the identified needs. ResultsTwo hundred and seventy one patients died in the center, out of which 234 relatives were contacted by phone. Kinship, gender and average age were spouse, female and 78 years old. Thirty five relatives required specific follow up by the psychologists. Cases that showed more complexity were one suicide attempt, 9 cases with severe depression, 5 cases struggling to deal with daily life problems, 8 cases of delayed grief and 3 cases of complicated grief. ConclusionsThe number of cases requiring specialized psychological care has been low. Psychological intervention has promoted adaptative grieving in the bereaved families. Monitoring and follow up are essential to identify those relatives that have actually required a specific intervention to prevent and treat properly complicated grief.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation

Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

Continuing Bonds, Risk Factors for Complicated Grief, and Adjustment to Bereavement

This study examined type of continuing bonds (CB) expression in relation to risk factors for complicated grief and measures of bereavement-related adjustment. Externalized CB expressions involving illusions and hallucinations with the deceased were distinguished from internalized CB expressions involving use of the deceased as an autonomy promoting secure base. 502 bereaved participants completed over the internet a CB measure assessing externalized and internalized CB along with various known risk-factor measures that included cause of death (i.e., violent vs. non-violent death), responsibility for the death, and attachment style as well as measures of psychological adjustment that included complicated grief symptoms, perceived physical health, and personal growth. As predicted, externalized CB was positively associated with violent death and responsibility for the death, whereas internalized CB was negatively associated with these risk factors as well as uniquely positively linked to personal growth. The implications of the findings for the role of CB in adjustment are discussed.