Research roundup: Spousal loss and bereavement care

Death is a universal life event and bereavement is its natural response. The loss of a loved one can impact an individual’s psychological, physical, and social state and adaptation can be difficult. As many as 10-15% of bereaved individuals develop complicated reactions (Bryant, 2013; Prigerson, 2004), such as depression, bereavement-related post-traumatic stress disorder, and prolonged grief disorder (PGD) (Maciejewski et al., 2016; Prigerson et al., 2009).

The following studies examine risk factors for prolonged grief disorder, resilience, and protective factors for positive adjustment, as well as successful mechanisms of treatment for complicated grief.

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Infurna, F.J., & Luthar, S.S. (2017). The multidimensional nature of resilience to spousal loss. Journal of Personality and Social Psychology, 112(6), 926-947. http://dx.doi.org/10.1037/pspp0000095.

Spousal loss can result in a variety of adjustment difficulties across different aspects of functioning, yet much previous research on resilience to bereavement focused on single measures of adjustment. In this study, the authors examined concordance across five different trajectories of resilience indices: life satisfaction, positive affect, negative affect, general health and physical functioning. They also looked at the role of potential vulnerability and protective factors that might exacerbate or reduce the negative effects of spousal loss. Those factors included expecting someone to offer them comfort when in distress (also referred to as “reliable comfort”), social connectedness, and engagement in everyday role activities, along with sociodemographic indices of age, gender, and education.

For this study, data from 421 participants who experienced spousal loss was taken from the larger Household Income and Labor Dynamics of Australia Study, a nationally representative annual panel study of households and their residents that began in 2001. Data was collected each year from household members aged 15 and older using a mixture of in-person and telephone interviews and self-completed questionnaires. At the time of spousal loss, participants’ average age was 69 years old, 71% were female and education ranged from less than high school to postgraduate degrees. Growth mixture modeling analyses using observations from both five years before and five years after spousal loss were conducted to ensure enough time had occurred to track change and enough statistical power to detect between-person differences in levels and rates of change.

Results demonstrated a wide range of percentages of individuals displaying resilient trajectories across the adjustment indices:

• 66% for life satisfaction
• 26% for positive affect
• 19% for negative affect
• 37% for perceptions of general health
• 28% for physical functioning

Only 8% of individuals showed resilience across all five dimensions and as many as 20% showed a non-resilient trajectory across all five. With respect to protective factors, being able to maintain one’s social connectedness with friends and family was strongly associated with resilience as was continued engagement in everyday life-role activities. Further, the anticipation that they would receive solace or comfort at times of distress was a significant protective factor. Resilience was not associated with age or education level in this study, but in the group that did not manifest resilience in any of the domain areas, females outnumbered males three to one.

Eckholdt, L., Watson, L., & O’Connor, M. (2017). Prolonged grief reactions after old age spousal loss and centrality of the loss in post loss identity. Journal of Affective Disorders, 227, 338–344. https://doi.org/10.1016/j.jad.2017.11.010.

Previous research has attempted to identify risk factors for the development of PGD and other adjustment difficulties. One possible risk factor may be the centrality of the loss to one’s identity. "Centrality of loss" refers to the degree to which the memory of the traumatic event is fundamental to one's everyday inferences, life-story, and identity. The present study sought to explore the relation of loss-centrality to post-loss pathology such as prolonged grief symptoms, posttraumatic stress symptoms, and depression in older bereaved individuals.

The participants consisted of 208 older Danish adults (mean age = 72) who had lost their spouse. Self-report questionnaires were completed at two months, six months and four years after the loss. The questionnaires included demographics, questions about the loss event and about the spousal relationship, as well as a number of measures to assess psychological well-being and event centrality including complicated grief, depression, trauma, and coping styles.

The authors found that the demographic variables did not correlate with complicated bereavement reactions and, therefore, were not included in the regression analyses. Results showed that higher levels of loss-centrality significantly predicted higher levels of prolonged grief symptoms, posttraumatic stress symptoms and depression four years after spousal loss. Further analyses found that feelings of distress associated with the loss-event two months after the loss predicted symptoms of prolonged grief, and elevated levels of emotional loneliness were found to predict symptoms of depression four years later.

Glickman, K., Shear, M., & Wall, M. (2016). Mediators of outcome in complicated grief treatment. Journal of Clinical Psychology, 73(7), 817–828. https://doi.org/10.1002/jclp.22384.

Individuals with complicated grief or prolonged grief disorder have responded positively to Complicated Grief Treatment (CGT) (Shear, et al., 2005; Shear et al., 2016). The treatment is designed to target grief complications such as dysfunctional thoughts or maladaptive self-blaming and facilitate healing by revitalizing social connections and guiding self-compassion. The current study examined the mechanisms of CGT by analyzing probable mediators between the treatment and outcomes based on data from a previous study. The mediators explored were guilt or self-blame, negative thoughts about the future, and avoidance.

Bereaved individuals who scored less than 30 on the Inventory of Complicated Grief (ICG) were included in the study and were randomly assigned to 16 sessions of manualized treatment of either CGT (n=35) or interpersonal therapy in which grief was the primary interpersonal problem area (n=34). Outcome variables were measured using the ICG, the Clinical Global Improvement, and the Work & Social Adjustment Scale. The researchers used items from the Structured Clinical Interview for Complicated Grief (SCI-CG) to assess guilt or self-blame, and self-report questionnaires for negative thoughts about the future and avoidance.

Using regression analysis, the results indicated that reductions in guilt or self-blame, negative thoughts about the future and avoidance behavior each mediated the relationship between treatment group and outcomes. Reduction in avoidance was the strongest mediator among the three, accounting for a high percentage of the treatment effect on grief symptoms. This finding suggests that reducing avoidance of thinking about the loss is one of the important components in effective treatment for bereaved individuals.

Individuals who have lost a spouse may be in need of professional assistance to cope and adapt to the subsequent life change. Relying on clients’ reports of life satisfaction might not be enough to demonstrate true adaptation or resilience to the loss event. Psychologists may wish to use other measures or discussions specifically regarding affect and physical functioning to obtain a full picture of their client’s adaptation to spousal loss.

Because of the close link between prolonged grief and the centrality of the loss to one’s identity, treatment strategies that address a client’s acceptance of the loss and help them to update their self-identity, including emphasizing memories of important life events that have occurred after the loss of their spouse, might be helpful. Revising counterfactual thinking (such as blaming oneself for a person’s death and believing life has no purpose without the loved one) may help patients cope with loss. Given the likelihood that perceived social isolation carries serious risks for several negative outcomes, psychologists may wish to address clients’ beliefs that they have no one to depend on as that belief could inhibit one’s proactive efforts to reach out to others for support in times of need. Remaining engaged in interactions and activities could also lead to better psychological and physical health.

Finally, the research findings suggest that reducing avoidance of thinking about the loss is one of the important components of helping bereaved individuals with prolonged grief. Clinicians can encourage their clients to continue the bonds with the deceased through memories and pictures, while at the same time guide their patients to reflect on the finality of the death. Assisting clients to confront the loss and consequences may help them to grieve appropriately but to also continue living.