Continuing Bonds in Marriage, Death and Divorce: Conceptual and Clinical Considerations in the Relationship to Self and Spouse.

The shift from the detachment model of mourning to the continuing bonds paradigm in bereavement placed relationships to the deceased alongside relationships to the living. This emphasis on the continuation of the connection to the other person after death paradoxically narrowed the gap between relationships in life and after death. We explore and expand the concept of continuing bonds as it is now used in the field of loss and bereavement by comparing spousal relationships in the living, deceased and divorced. The Two-Track Model of Loss and Bereavement is a framework and clinical paradigm that clarifies similarities and differences in these three pair-bond relationships. The focus on continuing bonds adds and deepens theory, clinical and research aspects of assessing spousal relationship for the living as well as the bereaved and divorced.

The Two-Track Model of Dementia Grief and spousal response to illness and death.

This cross-sectional study examined the experiences of healthy spouses caring for their partners via the Two-Track Model of Dementia Grief thereby broadening our understanding of the functional and relational aspects of this process. The 122 participating older adults had spouses drawn from four groups: mild to moderate cognitive-impairment; advanced cognitive-impairment; deceased following dementia; and, healthy controls. They completed a battery of self-report measures. Results showed elevated scores on both tracks of the model for all affected groups. Assisting spouses of those living with cognitive-impairment begins with the earliest symptoms of decline and continues after the death of the loved one.

Spousal Mourning for Partners Living with Cognitive Impairment: The Interplay of Attachment and the Two-Track Model of Dementia Grief.

The aim of the present research was to study the interplay of Attachment Theory and the Two-Track Model of Dementia Grief. To examine the research hypotheses, a cross-sectional study was designed and included 122 participants (Mean age = 72.77) drawn from four groups: spouses of people living with mild to moderate cognitive impairment, spouses of people living with advanced cognitive impairment, widowed spouses of deceased dementia patients, and a control group. Participants completed a battery of self-report questionnaires. Results showed that secure attachment constitutes a significant protective factor with regard to bio-psycho-social symptomatology (Track I) as well as difficulties in the relational bond with the spouse and grief over their deterioration (Track II). The results of the research support integrating attachment-based insights into clinical work with spouses coping with the losses accompanying cognitive decline and the grief processes that are operant in these losses.

The Two-Track Model of Dementia Grief (TTM-DG): The theoretical and clinical significance of the continuing bond in sickness and in death.

Grief and mourning for family members caring for a dementia patient begin with the initial changes in the person's cognitive abilities, and intensify with the worsening of his or her condition. The aim of this article is to propose a Two-Track Model of Dementia Grief (TTM-DG). This model enlarges the theoretical, research and clinical lenses for dementia, and explores how the illness process as well as the bereavement responses after death stimulate the reworking of grief and mourning over the beloved family member. Based on the insights derived from the Two-Track Model of Loss and Bereavement and the Continuing Bonds paradigm, we propose that the clinical and research examination of dementia grief begin in life and continue after the death. The TTM - DG's Track I focuses on bio-psycho-social functioning and Track II focuses on the internalized psychological representation of the patient, the ongoing relational bond and the illness and death story. A case study illustrates how this combined perspective provides a comprehensive picture of the experience of grief for persons afflicted with dementia over the course of the disease trajectory. Future clinical and empirical research has an important role to play in the further development of this model.

Widowhood in the Israeli Arab Muslim Society.

Adjustment of Israeli Arab Muslim widows to the traumatic loss of their husbands was examined by comparing their reported ways of coping with those of married women of their community by means of the Two-Track-Bereavement Model. Participants included 93 widows and 86 comparable married women who were mostly middle aged and of middle class. We hypothesized that widows will express concurrently greater suffering and higher resilience to adverse life events compared with married women. It was hypothesized further that positive and close relations to a deceased husband will be reported by Arab widows as well as Arab married women. However, positive relationships of married women will correlate with their own coping supporting attributes, whereas positive relations of widows to their deceased husband will not be associated with their individual characteristics. Results indicated a fourfold factor structure of the bereavement and coping scale which differed from those obtained by Israeli Jewish women and generally supported these hypotheses. It appears that traumatic loss of a husband may enhance widows' resilience.

Bereavement of Israeli Arab Muslim widows: Determinants of adjustment and supporting attributes.

Cultural-specific determinants of coping with widowhood were investigated by the Two-Track Model of Bereavement. Participants were 93 middle-aged and middle-class Israeli Arab Muslim widows. Factor analysis emitted 4 factors of adjusting to widowhood. The suffering and resilience factors and the total scale score were consistently correlated with personality attributes, whereas demographics were associated mainly with the suffering factor and the total scale score. The factors differed from the factors characteristic of Israeli Jewish bereaved, which emphasize the need to examine models of bereavement in cross-cultural perspective and to account for the interaction of cultural effects with psychological processes.

Risk, Resilience, and the Two-Track Model of Dementia Grief Among Spouses of People Living With Cognitive Decline.

Pre-death grief in the context of dementia caregiving is a significant risk factor for depression, burden, anxiety, and adjustment difficulties. The Two-Track Model of Dementia Grief (TTM-DG) provides a bifocal perspective addressing the nature of the emotional attachment to a loved one living with cognitive impairment, along with a medico-psychiatric perspective associated with stress, trauma, and change in life. The aims of the present study were to empirically validate the components of the model as to identify salutary and risk factors for maladaptive grief responses. Participants were 62 spouses of people living with cognitive impairment, and a control group of 32 spouses. All completed a battery of self-report questionnaires. Structural Equation Modeling yielded six variables consistent with the TTM-DG: partner's behavioral disorders; caregiver's burden; social support; physical health; attachment anxiety; and dementia grief as an outcome measure. Additional findings addressed participants at risk for grief difficulties. The findings provide empirical support for the utility of the TTM-DG in the identification of risk factors associated with maladaptive responses and pre-death grief following a spousal cognitive decline. The TTM-DG can assist in the formulation of evidence-based evaluations and interventions to assist spouses caring for their loved ones living with dementia.

Ethics at Israeli universities: unlearned lessons from professional ethics.

At the practical level, sustained attention to ethical issues in academia in Israel is inadequate. This paper suggests that professional models of ethics education and training present constructive alternatives. The author views this topic from the dual perspective of a professional clinical psychologist and a committed faculty member. After a brief introduction, the paper opens with a case vignette of ethical violations of trust in academia, its handling, and how a similar case 25 years later illustrates the lack of progress in preparing the academic community for such things. A discussion of normative actions and behavioral norms in academia follows. Three lessons from the professions are offered: 1) the importance of involving members in the process of identifying ethical violations; 2) the value of adopting for academia current practices preparing persons for work in research, (for example the standardization of online modules for training in ethics); and c) the significance of addressing self-interest and its limits. If silence around a code of ethics is being practiced, that silence should be broken.

Caregivers' Grief in Acquired Non-death Interpersonal Loss (NoDIL): A Process Based Model With Implications for Theory, Research, and Intervention.

The number of family members caring and caregiving for a loved one undergoing physical and mental changes continues to increase dramatically. For many, this ongoing experience not only involves the "burden of caregiving" but also the "burden of grief" as their loved-one's newfound medical condition can result in the loss of the person they previously knew. Dramatic cognitive, behavioral, and personality changes, often leave caregivers bereft of the significant relationship they shared with the affected person prior to the illness or injury. This results in what we term conditions of acquired "non-death interpersonal loss" (NoDIL). Current approaches to these losses use an amalgam of models drawn from both death and non-death loss. Despite their utility, these frameworks have not adequately addressed the unique processes occurring in the interpersonal sphere where the grieving caregiver needs to reach some modus vivendi regarding the triad of "who the person was," "who they are now," and "who they will yet become." In this paper we propose a process-based model which addresses cognitive-emotional-behavioral challenges caregivers meet in the face of their new reality. These require a revision of the interpersonal schemas and the relationships that takes into account the ongoing interactions with the affected family member. The model and its utility to identify adaptive and maladaptive responses to NoDIL is elaborated upon with clinical material obtained from caregivers of people diagnosed with major neuro-cognitive disorder and pediatric traumatic brain injury. The article concludes with implications for theory, research and clinical intervention.

Traumatic Bereavements: Rebalancing the Relationship to the Deceased and the Death Story Using the Two-Track Model of Bereavement.

Bereavements that occur under external traumatic circumstances increase the risk for dysfunction, trauma symptomatology, as well as disordered and prolonged grief. While the majority of individuals who have experienced traumatic bereavements do not meet formal criteria for posttraumatic stress disorder (PTSD), persistent complex bereavement disorder (PCBD), or prolonged grief disorder (PGD), the degree of distress and dysfunction for these bereaved can be quite significant. The assessment and intervention paradigms in use with traumatic bereavements often prioritize the trauma and bypass the centrality of the interpersonal loss. By using a bifocal approach in conceptualizing bereavement, the Two-Track Model of Bereavement (TTMB) rebalances the approach to the class of traumatic bereavements. Track I examines biopsychosocial functioning and symptoms of trauma, and track II focuses on the nature of the ongoing relationship with the deceased and the death story that may also have elements of traumatic response. The model and its application serve to identify both adaptive and maladaptive responses to loss along both axes to optimally focus interventions where needed. The story of the death, the psychological relationship with the deceased, and the presence of biopsychosocial difficulties each have a part to play in assessment and intervention. A case study of assessment and intervention following traumatic bereavement due to suicide illustrates how attention to each of these factors in the TTMB can facilitate change. Ultimately, the relational bond with the deceased is a major vector in grief and mourning. Assessment and intervention with traumatic bereavements require attention to dysfunction and symptoms of trauma as well as to the death story and the state of the relationship to the deceased.

Loss and mourning in the Jewish tradition.

Robert Kastenbaum was a man who helped reintroduce issues related to death, dying, and bereavement to academic, clinical, and general discourse. This article, devoted to an encounter with the observance of mourning custom and ritual in the Jewish tradition, continues the dialogue in this journal that Bob founded. The article utilizes the Two-Track Model of Bereavement to address the Jewish tradition's structuring of the loss experience. After a brief introduction, I present a schematic presentation of some of the issues operant in grief and mourning for the believer. This is followed by two responses to loss that portray the pain of loss in the tradition. The article goes on to consider the Jewish time cycle of response to loss-from preburial Aninut, to Shiva, the first week, to Shloshim, the first month, to Shanah, the first year, to the expectations for encounters across the life cycle. The Yizkor and Kaddish are also considered. In the Jewish tradition, alongside attention to what level of functioning to require of the bereaved, there are lifelong opportunities to re-work and maintain connection to the memories, associations, narratives, and experiences that comprise the psychological organization of the continuing bond and relationship to the deceased.

The continuing bonds of bereaved parents: a ten-year follow-up study with the two-track model of bereavement.

This article examines how varieties of the continuing relationship to the deceased child are associated with life functioning among bereaved parents. The research employed a longitudinal design utilizing both quantitative and qualitative research methodology. Six bereaved parents who lost sons in war and who had extensive interview material and research protocols spaced 10 years apart were selected for this study. Half had improved over time and half had not improved or deteriorated. Analyses of the ongoing relationship to the deceased focused upon: (a) perceptions of the deceased and (b) nature of the ongoing relationship to the deceased son. On perception, parents who improved tended to describe their sons in very favorable terms. The parents whose condition remained static or deteriorated tended to describe their sons less positively, and with superficial and shallow descriptions. Regarding the nature of the ongoing relationship, parents whose condition improved over the years describe a close and significant relationship with the son. We conclude that while the relationship to the son continues for all the bereaved parents, it is how the deceased is recollected that is associated with the direction of bereavement outcome.

The two-track model of bereavement questionnaire (TTBQ): development and validation of a relational measure.

The Two-Track Model of Bereavement Questionnaire (TTBQ) was designed to assess response to loss over time. Respondents were 354 persons who completed the 70-item self-report questionnaire constructed in accordance with the Two-Track Model of Bereavement. Track I focuses on the bereaved's biopsychosocial functioning and Track II concerns the bereaved's ongoing relationship to the range of memories, images, thoughts, and feeling states associated with the deceased. Factor analysis identified 5 factors that accounted for 51% of the variance explained. In accord with the theoretical and clinical model, 3 factors were primarily associated with the relationship to the deceased (Track II): Active Relational Grieving, Close and Positive Relationship, and Conflictual Relationship; and 2 factors with aspects of functioning (Track I): General Biopsychosocial Functioning and Traumatic Perception of the Loss. Construct and concurrent validity were examined and were found satisfactory. Differences by kinship, cause of death, gender, and time elapsed were examined across the 5 factors, the total TTBQ, and the ITG. The new measure is shown to have both construct and concurrent validity. Discussions of the results and implications for the measurement of response to loss conclude the article.

Therapeutic issues and the relationship to the deceased: working clinically with the two-track model of bereavement.

Psychological intervention with the bereaved can provide critical assistance to individuals, families, and communities contending with the loss of significant others. In the organizational paradigm of the Two-Track Model of Bereavement, the outcome of both successful and problematic mourning are manifest along two distinct but interrelated tracks of functioning and relationship to the deceased. Reworking relationships to the deceased can help people resume authorship of their life narratives following loss. Two cases of spousal death are presented and significant features of the treatments discussed. The Two-Track Model of Bereavement emphasizes that the dimensions of a person's functioning reflect only part of the response to loss. The ongoing relationship with the complex of memories, thoughts, emotions, and needs associated with the person who has died is no less important. Although the domains of general functioning and relationship to the deceased are related, they are far from identical. Attending to the memories and emotions bound up with the deceased should continue to demand our sustained attention as therapists.

The meaning structures of Muslim bereavements in Israel: religious traditions, mourning practices, and human experience.

The grief and mourning of Muslim citizens in Israel are considered. First, a series of mourning customs spanning the period from notification of death until post-mourning are presented from 3 perspectives: (a) the requirements of the Islamic Sunni tradition; (b) the manner in which Islamic mourning rituals are practiced; and (c) the authors' interpretative perspective. Next, a synopsis of the personal experiences of two adult children to the death of their elderly father illustrates Muslim bereavement from a narrative point of view. Lastly, the concluding section continues a consideration of the distinction between the Islamic religious emphasis on return to functioning and the myriad ways in which the memory and relationship to the deceased are experienced. The article demonstrates how belief system, Islamic mourning rituals, and the power of loss create an experiential blend that is neither monolithic nor stereotypical.

Professional ethics of psychologists and physicians: morality, confidentiality, and sexuality in Israel.

Clinical psychologists' and nonpsychiatric physicians' attitudes and behaviors in sexual and confidentiality boundary violations were examined. The 171 participants' responses were analyzed by profession, sex, and status (student, resident, professional) on semantic differential, boundary violation vignettes, and a version of Pope, Tabachnick, and Keith-Spiegel's (1987) ethical scale. Psychologists rated sexual boundary violation as more unethical than did physicians (p less than .001). Rationale (p less than .01) and timing (p less than .0001) influenced ratings. Psychologists reported fewer sexualized behaviors than physicians (p less than .05). Professional experience (p less than .01) and sex (p less than .05) were associated with confidence-violating behavior. Overall, 78% of the sample reported attitudes or behaviors associated with boundary violations. The behavior violations were correlated (r = .49). Actual violators rated vignette violators more leniently than did nonviolators (p less than .01).

Trauma and bereavement: conceptual and clinical issues revolving around relationships.

The article re-examines trauma and bereavement and the category of loss considered to be traumatic bereavement. It is argued that the perspective of the relation to the deceased is an insufficiently acknowledged source of traumatic disruption following bereavement. The significance of the relational aspect in bereavement is present in the paradigm of the Two-Track Model of Bereavement (S. Rubin, 1981, 1999). The implications of this approach are examined in the case of a soldier exposed to trauma and death. The case is examined from a traditional trauma perspective stressing exposure to life threat and again from a perspective stressing the significance of the relationship to the deceased. An examination of the different intervention strategies and their outcome lends support to the importance of the relational aspects in this case of trauma and supports the use of the Two-Track Model of Bereavement. The location of trauma as basic to the experience of all bereavement for its impact on the reorganization vis a vis the representation of the loved one now deceased is considered as fundamental to the trauma of all bereavement. The additional contribution of bereavement occurring under conditions of life threat (traumatic situations) is an important feature potentially impacting the bereavement process, but it is not what makes bereavement traumatic per se. An additional source of trauma in bereavement, occurring when the previous representation or introject of the deceased is shattered, is considered for its status as an additional source of complication in the traumas of bereavement.