Regret and unfinished business in parents bereaved by cancer: A mixed methods study.

BACKGROUND: Prior research has demonstrated that the presence of regret and unfinished business is associated with poorer adjustment in bereavement. Though there is a growing literature on these constructs among caregivers of adult patients, the literature on regret and unfinished business in bereaved parents has been limited. AIM: The aim of this study was to examine regret and unfinished business in parents bereaved by cancer, as well as their associations with caregiving experiences and prolonged grief. DESIGN: This was a cross-sectional mixed methods study that utilized self-report questionnaires with open-ended items. SETTING/PARTICIPANTS: The multisite study took place at a tertiary cancer hospital and pediatric cancer clinical research institution. Participants were 118 parents (mothers = 82, fathers = 36) who lost a child aged 6 months to 25 years to cancer between 6 months and 6 years prior. RESULTS: Results showed that 73% of the parents endorsed regret and 33% endorsed unfinished business, both of which were more common among mothers than fathers (p ⩽ 0.05). Parents were on average moderately distressed by their regrets and unfinished business, and both regret-related and unfinished business-related distress were associated with distress while caregiving and prolonged grief symptoms. CONCLUSION: Findings have implications for how providers work with families, including increasing treatment decision-making support, supporting parents in speaking to their child about illness, and, in bereavement, validating choices made. Grief interventions that use cognitive-behavioral and meaning-centered approaches may be particularly beneficial.

The Unfinished Business in Bereavement Scale (UBBS): Development and psychometric evaluation.

Although unresolved issues with the deceased are often targeted in bereavement interventions, understanding of this construct has been hampered by the lack of a psychometrically validated scale to assess it. To address this gap, the Unfinished Business in Bereavement Scale (UBBS) was developed and tested in two samples of bereaved adults (n = 292 and 168). In exploratory and confirmatory factor analyses, the UBBS was found to be composed of two related factors. Items tapping into Unfulfilled Wishes pertained to unspoken affirmations or missed opportunities with the deceased. These experiences often emerged in loving relationships and only became problematic when accompanied by high levels of distress. In contrast, Unresolved Conflict pertained to unaddressed disputes or indiscretions. It primarily occurred in relationships characterized by anxiety and conflict and conferred risk for prolonged grief reactions even when endorsed at moderate levels. Other findings strongly supported the internal consistency, concurrent validity, and incremental validity of the UBBS. Unfinished business and meaning made of loss together accounted for 50-60% of the variance in prolonged grief symptoms. Implications for clinical practice and future research are discussed.

Bereavement-related regrets and unfinished business with the deceased.

Unresolved relational issues with the deceased have been considered a prominent risk factor for negative bereavement outcomes. However, this area of study has suffered from a lack of conceptual clarity, with some commentators focusing on bereavement-related regret and others focusing on "unfinished business," or lingering or unspoken conflicts with the deceased. This study examined the two concepts in a sample of 229 bereaved individuals, finding them to be overlapping but distinct constructs. Unfinished business occurred more frequently with immediate family and friends and in cases of sudden and violent death of loved ones. Both forms of unresolved issues were associated with bereavement outcome, with the relation between distress over unfinished business and complicated grief symptomatology being particularly robust.

The Link between Activities of Daily Living and Cortisol in Late-Life Depression.

OBJECTIVES: Dysregulated cortisol in older individuals is associated with neurodegeneration and executive dysfunction, among other negative health outcomes. Executive functioning deficits are believed to underlie declines in functioning among older adults. Despite these associations, there is limited research examining the relationship between cortisol and impaired functional status. METHODS: The present study examined the relationship between cortisol and functional status in a community sample of 51 older adults with depression. Pearson correlations and ordinal regressions were used to determine whether greater cortisol dysregulation was associated with ADL and IADL impairment. RESULTS: Results indicated that individuals who had higher levels of cortisol also tended to demonstrate greater functional deficits. These findings remained true when functional status was measured by either a clinician-rated tool or a self-report measure. CONCLUSIONS: The results of this study provide preliminary support for the hypothesis that elevated cortisol, in the context of depression, is associated with functional status deficits in older adults. CLINICAL IMPLICATIONS: Findings from this study begin to fill the gap in research examining the relationship between cortisol and functional impairment in older adults and suggest that unique information can be gathered with the use of different functional status measures.

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.

A qualitative study of the emotional and spiritual needs of Hispanic families in hospice.

BACKGROUND: As the older U.S. population becomes more ethnically diverse, there will be an increased need for culturally sensitive hospice care services. Hispanics often experience multiple barriers to quality end-of-life care services. OBJECTIVE: To address the underlying disparities in the cultural, emotional, and spiritual aspects of hospice care, the objective of the present qualitative study was to examine the emotional and spiritual needs of Hispanic patients' families while in hospice. METHOD: Semistructured in-person interviews were conducted with 29 Hispanic patients' families regarding their perceived experience of the hospice-based emotional and spiritual support received. Demographic information was collected on both the family member and the patient. Interviews were digitally recorded, transcribed, and analyzed using thematic content analysis. RESULTS: Participant narratives fell into five main themes: (1) the influence of Hispanic culture in the relationship with hospice care providers; (2) types of social support received from hospice; (3) barriers to receiving support; (4) lack of health literacy regarding hospice care; and (5) cultural preferences for religious/spiritual support in hospice. SIGNIFICANCE OF RESULTS: Our results provide insight into the specific emotional and spiritual needs of Hispanic families receiving hospice services. Our findings highlight that cultural values play an important role in the hospice care experiences of Hispanic families.

Family Behavior Therapy for Alcohol and Drug Problems in Later-Life.

Alcohol and drug use problems among older individuals are a growing public health concern. However, few treatments have been developed for this population, despite an emerging body of literature suggesting that older substance users are more likely to benefit from interventions tailored to meet their specific needs. In particular, older adults with a history of substance abuse have expressed a preference for treatments that focus on financial problems, physical health, and mobility issues, and make attempts to prescriptively involve supportive others in treatment. To address these needs, we developed a modified version of Family Behavior Therapy (FBT) for older individuals with substance use problems that involves participation from significant others and covers skills that are relevant to an older clientele. This modified form of FBT is illustrated through the case of Jack-a 55-year-old man with a longstanding addiction to methamphetamine. After completing 16 sessions, Jack's alcohol and drug use was substantially reduced, and he reported strong confidence in his ability to resist substance use in the future. Despite this promising first case, further work is needed to fully examine the efficacy of this modified version of FBT for older individuals with substance use problems.

The impact of executive function on response to cognitive behavioral therapy in late-life depression.

OBJECTIVE: Late-life depression (LLD) is a common and debilitating condition among older adults. Cognitive behavioral therapy (CBT) has strong empirical support for the treatment of depression in all ages, including in LLD. In teaching patients to identify, monitor, and challenge negative patterns in their thinking, CBT for LLD relies heavily on cognitive processes and, in particular, executive functioning, such as planning, sequencing, organizing, and selectively inhibiting information. It may be that the effectiveness of CBT lies in its ability to train these cognitive areas. METHODS: Participants with LLD completed a comprehensive neuropsychological battery before enrolling in CBT. The current study examined the relationship between neuropsychological function prior to treatment and response to CBT. RESULTS: When using three baseline measures of executive functioning that quantify set shifting, cognitive flexibility, and response inhibition to predict treatment response, only baseline Wisconsin Card Sort Task performance was associated with a significant drop in depression symptoms after CBT. Specifically, worse performance on the Wisconsin Card Sort Task was associated with better treatment response. CONCLUSIONS: These results suggest that CBT, which teaches cognitive techniques for improving psychiatric symptoms, may be especially beneficial in LLD if relative weaknesses in specific areas of executive functioning are present.

FMRI activation during executive function predicts response to cognitive behavioral therapy in older, depressed adults.

OBJECTIVES: To test our hypothesis that pre-treatment executive function and brain regional activation during executive function would discriminate between responders and non-responders to cognitive behavioral therapy (CBT) in elderly depressed outpatients. DESIGN: Clinical cohort study. SETTING: University-affiliated hospital. PARTICIPANTS: Sixty outpatients (age 59 years and older) completed 12 weeks of CBT between July 2010 and December 2011. Forty-four completed fMRI procedures. MEASUREMENTS: The main outcome consisted of a conversion from a clinical diagnosis (Mini-International Neuropsychiatric Interview) of depression to no clinical diagnosis of depression or a significant improvement in diagnostic criteria. Brain activation measured by functional magnetic resonance imaging during the Wisconsin Card Sorting task (WCST) was the primary predictor variable. RESULTS: 67% of patients had a positive response to CBT. Decreased activation in the left inferior frontal triangle and right superior frontal gyrus as well as increased activity in the right middle frontal gyrus and left superior frontal gyrus predicted a positive response to CBT. Demographic and neurocognitive measures of WCST performance were not significant predictors of a positive CBT outcome, whereas the measure of WCST-induced activity in the prefrontal cortex was a significant predictor. CONCLUSIONS: These data are among the first to suggest that measures of prefrontal brain activation during executive functioning predict response to CBT in older adults. Further exploration of the specific underlying processes that these prefrontal cortical regions are engaging that contributes to better CBT outcomes is warranted in larger, randomized studies.

Spirituality factors in the prediction of outcomes of PTSD treatment for U.S. military veterans.

Spirituality is a multifaceted construct that might affect veterans' recovery from posttraumatic stress disorder (PTSD) in adaptive and maladaptive ways. Using a cross-lagged panel design, this study examined longitudinal associations between spirituality and PTSD symptom severity among 532 U.S. veterans in a residential treatment program for combat-related PTSD. Results indicated that spirituality factors at the start of treatment were uniquely predictive of PTSD symptom severity at discharge, when accounting for combat exposure and both synchronous and autoregressive associations between the study variables, ßs = .10 to .16. Specifically, veterans who scored higher on adaptive dimensions of spirituality (daily spiritual experiences, forgiveness, spiritual practices, positive religious coping, and organizational religiousness) at intake fared significantly better in this program. In addition, possible spiritual struggles (operationalized as negative religious coping) at baseline were predictive of poorer PTSD outcomes, ß = .11. In contrast to these results, PTSD symptomatology at baseline did not predict any of the spirituality variables at posttreatment. In keeping with a spiritually integrative approach to treating combat-related PTSD, these results suggest that understanding the possible spiritual context of veterans' trauma-related concerns might add prognostic value and equip clinicians to alleviate PTSD symptomatology among those veterans who possess spiritual resources or are somehow struggling in this domain.

Unfinished Business in Bereavement.

Unfinished business (incomplete, unexpressed or unresolved relationship issues with the deceased) is frequently discussed as a risk factor for chronic and severe grief reactions. However, few empirical studies have examined this construct. The present study aimed to address this gap in the literature by examining the presence and severity of unfinished business as well as common themes of unfinished business reported in open-ended qualitative narratives among a sample of 224 bereaved individuals. In bivariate analyses, self-reported presence of unfinished business and the severity of distress due to unfinished business were both found to be associated with poorer bereavement outcomes. However, after controlling for potential confounds, distress related to unresolved issues with the deceased emerged as a more robust correlate of these outcomes. Qualitative responses were categorized, and the type of reported unfinished business was not significantly related to the degree of unfinished business distress or other bereavement outcomes. These findings provide preliminary justification for bereavement interventions that aim to ameliorate distress related to unresolved relational issues with the deceased.

Moral injury, meaning making, and mental health in returning veterans.

OBJECTIVE: This study examined whether exposure to morally injurious experiences (MIEs) contribute to mental health problems among returning Veterans via meaning made of possible traumas. METHOD: A total of 131 Iraq and/or Afghanistan Veterans completed assessments of exposure to possible warzone traumas, meaning made of a salient stressor from their lives, and mental health symptomatology (e.g., posttraumatic stress, depression, suicidality). RESULTS: Structural equation modeling findings revealed that MIEs were indirectly linked with mental health outcomes via the extent to which Veterans were able to make meaning of their identified stressors. However, we also found that the direct path from MIEs to mental health problems was statistically significant. CONCLUSION: These findings provide preliminary evidence that difficulties with meaning making could serve as a mediating pathway for how MIEs increase the risk for adjustment problems after warzone service, but that other factors associated with moral injury also have a bearing on psychological functioning among Veterans.

Initial psychometric evaluation of the Moral Injury Questionnaire--Military version.

UNLABELLED: Moral injury is an emerging construct related to negative consequences associated with war-zone stressors that transgress military veterans' deeply held values/beliefs. Given the newness of the construct, there is a need for instrumentation that might assess morally injurious experiences (MIEs) in this population. Drawing on a community sample of 131 Iraq and/or Afghanistan Veterans and clinical sample of 82 returning Veterans, we conducted an initial psychometric evaluation of the newly developed Moral Injury Questionnaire-Military version (MIQ-M)-a 20-item self-report measure for assessing MIEs. Possibly due to low rates of reporting, an item assessing sexual trauma did not yield favourable psychometric properties and was excluded from analyses. Veterans in the clinical sample endorsed significantly higher scores across MIQ-M items. Factor analytic results for the final 19 items supported a unidimensional structure, and convergent validity analyses revealed that higher scores (indicative of more MIEs) were correlated with greater general combat exposure, impairments in work/social functioning, posttraumatic stress and depression in the community sample. In addition, when controlling for demographics, deployment-related factors and exposure to life threat stressors associated with combat, tests of incremental validity indicated that MIQ-M scores were also uniquely linked with suicide risk and other mental health outcomes. These findings provide preliminary evidence for the validity of the MIQ-M and support the applicability of this measure for further research and clinical work with Veterans. KEY PRACTITIONER MESSAGE: Military service can confront service members with experiences that undermine their core sense of humanity and violate global values and beliefs. These types of experiences increase the risk for posttraumatic maladjustment in this population, even when accounting for rates of exposure to life threat traumas. Moral injury is an emerging construct to more fully capture the many possible psychological, ethical, and spiritual/existential challenges among persons who served in modern wars and other trauma-exposed professional groups. There is currently a need for psychometrically sound instrumentation for assessing morally injurious experiences (MIEs). The Moral Injury Questionnaire - Military Version (MIQ-M) was developed to provide a tool for assessing possible MIEs among military populations. This study provides preliminary evidence of the validity - including factorial, concurrent, and incremental - and clinical utility of the MIQ-M for further applications in clinical and research contexts.

Family evaluation of hospice care: Examining direct and indirect associations with overall satisfaction and caregiver confidence.

OBJECTIVE: The Family Evaluation of Hospice Care (FEHC) survey is widely employed by hospices, and several studies have examined this information to help inform and enhance end-of-life services. However, these studies have largely focused on examining relatively straightforward associations between variables and have not tested larger models that could reveal more complex effects. The present study aimed to examine the direct and mediating (i.e., via information/education, patient care, and family support) effects of demographic factors, length of stay, timing of referral, patient symptom severity, location of services, and relationship to caregiver on two outcome variables: overall satisfaction and caregiver confidence. METHOD: Surveys were collected from 3226 participants who had lost a loved one who received hospice services. Structural equation modeling was employed to examine the direct and mediating effects of the independent variables on the two outcomes of interest. RESULTS: Participants reporting on racial minority patients, patients with more symptoms, and those referred too late or too early were the most likely to express some discontentment with hospice services. The information/education these individuals received was the only mediating factor significantly associated with caregiver confidence. More positive perceptions of patient care and information/education were both significantly related to greater overall satisfaction. SIGNIFICANCE OF RESULTS: These findings help to (1) pinpoint those most at risk for being less satisfied with hospice, (2) identify which aspects of care may be most strongly related to overall outcomes, and (3) provide a model for examining complex associations among FEHC variables that may be employed by other researchers.

Psychosocial predictors of salivary cortisol among older adults with depression.

ABSTRACT Background: Previous studies have identified a number of psychosocial risk factors of dysregulated cortisol (frequently referred to as the "stress hormone") among older adults with depression. However, these studies have typically only examined a handful of risk factors at a time and have sometimes yielded inconsistent results. Method: This study aims to address this gap in the literature by simultaneously examining a range of relevant psychosocial predictors of diurnal cortisol among 54 older adults with a depressive disorder. Salivary cortisol was assessed upon awakening, at 5 PM, and at 9 PM across two consecutive days. Participants also completed measures of global psychosocial stress, current psychiatric symptomatology, pervasive distress (e.g. history of past depression), and protective factors (e.g. social support, resiliency, extent to which one has "made sense" of a significant stressor). Results: High levels of current depressive symptoms, psychiatric comorbidities, past depressive episodes, trait anxiety, and poorer ability to make sense of one's stress were found to be associated with flatter (more abnormal) cortisol slopes. However, when all of these variables were entered simultaneously in a multiple regression analysis, only history of past depression and the degree of sense made of stress emerged as unique predictors of cortisol in the model. Conclusions: These findings have important implications for identifying depressed elderly individuals with dysregulated cortisol patterns who may be most at risk for health complications. Treatments that aim to limit the chronicity of depression and help to increase the sense made of stress could potentially have a positive impact on health.

Psychosocial predictors of treatment response to cognitive-behavior therapy for late-life depression: an exploratory study.

OBJECTIVE: The primary objective of this study was to examine a variety of potential predictors of response to Cognitive Behavioral Therapy (CBT) in depressed older adults. METHOD: Sixty older adults with a clinical diagnosis of major or minor depression or dysthymic disorder received 12 individual sessions of CBT over a three- to four-month-period. The BDI-II was administered pre- and post-intervention to assess change in the level of depression. A cutoff score of 13 or less at post was used to determine positive treatment response. A variety of measures (obtained at baseline) were evaluated using hierarchical regression techniques to predict improvement following treatment. RESULTS: Individuals who showed greater improvement were: (a) more open to new experiences; (b) less negatively affected by past stressors; (c) less inclined to have an external locus of control but more likely to cite others as responsible for negative stress in their lives; and (d) were more likely to seek emotional support when symptomatic. Lower education level and reported use of active coping strategies at baseline were associated with less improvement. Other variables (e.g., age, overall physical health, and cognitive status) were not associated with treatment response. Use of logistic regression to predict responders vs. nonresponders yielded a similar pattern. CONCLUSION: These findings agree with prior research confirming the effectiveness of a brief CBT intervention for older depressed persons and suggest further exploration of several psychosocial factors that may contribute to a stronger response to CBT.

Examining the role of combat loss among Vietnam War Veterans.

Military combat often presents service members with a dual burden of coping with traumas of various types while also grappling with the deaths of close personal friends. At present, much less is known about the effects of bereavement in the context of war compared to other combat-related stressors. Studying a sample of combat veterans from the National Vietnam Veterans Readjustment Study (NVVRS), we examined the contribution of combat loss in psychological functioning and posttraumatic stress disorder (PTSD). When controlling for gender, age, ethnicity, educational background, exposure to nonbereavement combat stressors, and recent bereavement experiences, combat loss was uniquely associated with past and current functional impairments among the veterans, ßs = .07 and .06, respectively, but was not related to the severity of PTSD. These findings highlight that combat loss might act as a uniquely challenging stressor among many service members and more empirical research is needed on this topic.

Attachment and mental health symptoms among U.S. Afghanistan and Iraq veterans seeking health care services.

Attachment theory has become a primary framework for understanding adjustment to traumas. In a convenience sample of 157 U.S. service members from the Afghanistan and Iraq wars seeking health care services at a Veterans Administration (VA) hospital, this study examined (a) the impact of attachment characteristics on several key mental health symptoms in this new generation of veterans, (b) the relative frequencies of prominent attachment styles in the sample, and (c) how these higher order orientations related to study outcomes. First, with demographic and military background factors in the model, attachment-related anxiety and avoidance were each uniquely associated with posttraumatic stress symptoms (PTSS), psychiatric distress, and alcohol misuse, ßs = .25 to .60. Second, latent class analysis highlighted the underrepresentation of avoidant veterans of a dismissive type in the sample. Third, of the different possible types of attachment insecurities, veterans with a fearful disorganized orientation were also shown to be particularly vulnerable to PTSS and other problems, even when compared to preoccupied-dependent persons. These findings yield further support for the protective benefit of attachment security, while also suggesting the importance of both attachment anxiety and avoidance in the context of postdeployment adjustment.

Meaning made following deployment in Iraq or Afghanistan: examining unique associations with posttraumatic stress and clinical outcomes.

Crises in personal meaning may be a critical aspect of psychological maladjustment following combat. Using the newly developed Integration of Stressful Life Events Scale (ISLES), this study examined the role of meaning made of a salient stressor following a combat deployment in Iraq or Afghanistan. In a sample of 169 returning service members, findings supported the distinctiveness of meaning made of a stressor (as assessed by the ISLES), factor analytically and as a correlate of several relevant clinical outcomes. In particular, when the model contained potential confounds and psychiatric symptoms, meaning made in the months and years following combat was uniquely associated with the severity of posttraumatic stress symptoms, ß = -.39, and referrals for mental health care, ß = -.69, in the sample. The present findings highlight the importance of the subjective meaning made of traumatic life events and also suggest that posttraumatic stress and other psychiatric symptomatology may not account for the full clinical picture among many service men and women.

Intraclass correlation associated with therapists: estimates and applications in planning psychotherapy research.

It is essential that outcome research permit clear conclusions to be drawn about the efficacy of interventions. The common practice of nesting therapists within conditions can pose important methodological challenges that affect interpretation, particularly if the study is not powered to account for the nested design. An obstacle to the optimal design of these studies is the lack of data about the intraclass correlation coefficient (ICC), which measures the statistical dependencies introduced by nesting. To begin the development of a public database of ICC estimates, the authors investigated ICCs for a variety outcomes reported in 20 psychotherapy outcome studies. The magnitude of the 495 ICC estimates varied widely across measures and studies. The authors provide recommendations regarding how to select and aggregate ICC estimates for power calculations and show how researchers can use ICC estimates to choose the number of patients and therapists that will optimize power. Attention to these recommendations will strengthen the validity of inferences drawn from psychotherapy studies that nest therapists within conditions.