Meaning reconstruction 70 years later: Processing older adults' unfinished business in a drama therapy group.

Unfinished business (UB), when individuals appraise their relationship with others or themselves as incomplete or unresolved, entails difficult emotions such as regret, remorse, and guilt. UB is often associated with bereavement and is considered to be a predictor of complicated grief. Here we report two case studies describing the processing of the sudden death of a significant other in the context of a randomized controlled study of 12-week drama therapy groups for older adults. The intervention followed the format of Playback Theater, an improvised form of theater based on personal stories, and a life review paradigm. A mixed-methods approach explored the course of individual therapy within the group and potential mechanisms of change. The participants completed mental health questionnaires in a pre-post-follow-up design. The qualitative data included video recordings and postintervention interviews. One participant reported a clinically significant (CS) change in depressive symptoms and psychological well-being on the post and follow-up measurement indices. The second reported a CS change in self-esteem and relationship satisfaction at the end of the intervention, but not at follow-up. The findings suggest that the drama therapy contributed to the resolution of UB through restorative work in the three domains defined in meaning reconstruction theory: the "event story" of the loss, the "back story" of the relationship with the deceased, and the "personal story" of self. The results point to the need for additional research on meaning reconstruction in the context of drama therapy and encourage the broader application of performative techniques to treat complicated bereavement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Inventory of Complicated Spiritual Grief 2.0 (ICSG 2.0): Validation of a revised measure of spiritual distress in bereavement.

Spirituality has long served as a source of solace for many grievers following a loss. For other mourners, whose bereavement experience has been significantly challenged by struggles in their relationship with God and/or their faith community, the opposite is true. Complicated spiritual grief (CSG) is a spiritual crisis following the loss of a loved one. To assess CSG in samples of bereaved adults, a simple-to-use, multidimensional measure of spiritual crisis following loss called the Inventory of Complicated Spiritual Grief (ICSG) was previously developed and validated. However, subsequent research providing greater clarity about the construct of CSG supported the need to revise and update the ICSG. The goal of the present study was to establish the psychometric validity of a revised measure of CSG, called the Inventory of Complicated Spiritual Grief 2.0 (ICSG 2.0), with a large, diverse cohort of bereaved Christian adults (N = 440). Analyses of the bifurcated sample supported a three-factor model measuring insecurity with God, estrangement from the spiritual community, and disruption in religious practices. Further analyses supported the convergent and incremental validity of a 28-item scale relative to other theoretically similar instruments and measures of poor bereavement outcome, indicating the instrument's research and clinical usefulness.

Performative retelling: Healing community stories of loss through Playback Theatre.

Restorative retelling (RR) is an evidence-based procedure for facilitating adaptation following traumatic bereavement. In this paper, we introduce performative retelling (PR), a variation on RR, which fosters healing from personal losses and portrays personal reactions to collective tragedy. We describe our collaboration with an ex-offender reentry program, the Memphis Police Department, and Playback Theatre to use improvisational community theatre to bridge the gap between law enforcement and the citizens they serve. We review program outcomes to-date and illustrate its impact using participant stories. We argue that training police and citizens in PR can potentially transform broken narratives of police-community relations.

A novel Family Dignity Intervention (FDI) for enhancing and informing holistic palliative care in Asia: study protocol for a randomized controlled trial.

BACKGROUND: The lack of a holistic approach to palliative care can lead to a fractured sense of dignity at the end of life, resulting in depression, hopelessness, feelings of being a burden to others, and the loss of the will to live among terminally ill patients. Building on the clinical foundation of Dignity Therapy, together with the empirical understanding of dignity-related concerns of Asian families facing terminal illness, a novel Family Dignity Intervention (FDI) has been developed for Asian palliative care. FDI comprises a recorded interview with a patient and their primary family caregiver, which is transcribed, edited into a legacy document, and returned to the dyads for sharing with the rest of the patient's family. The aims of this study are to assess the feasibility, acceptability and potential effectiveness of FDI in reducing psychosocial, emotional, spiritual, and psychophysiological distress in community-dwelling and in-patient, Asian, older terminally ill patients and their families living in Singapore. METHODS/DESIGN: An open-label randomized controlled trial. One hundred and twenty-six patient-family dyads are randomly allocated to one of two groups: (1) an intervention group (FDI offered in addition to standard psychological care) and (2) a control group (standard psychological care). Both quantitative and qualitative outcomes are assessed in face-to-face interviews at baseline, 3 days and 2 weeks after intervention, as well as during an exit interview with family caregivers at 2 months post bereavement. Primary outcome measures include sense of dignity for patients and psychological distress for caregivers. Secondary outcomes include meaning in life, quality of life, spirituality, hopefulness, perceived support, and psychophysiological wellbeing, as well as bereavement outcomes for caregivers. Qualitative data are analyzed using the Framework method. DISCUSSION: To date, there is no available palliative care intervention for dignity enhancement in Asia. This first-of-its-kind study develops and tests an evidence-based, family driven, psycho-socio-spiritual intervention for enhancing dignity and wellbeing among Asian patients and families facing mortality. It addresses a critical gap in the provision of holistic palliative care. The expected outcomes will contribute to advancements in both theories and practices of palliative care for Singapore and its neighboring regions while serving to inform similar developments in other Asian communities. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03200730 . Registered on 26 June 2017.

Assessing a Buddhist treatment for bereavement and loss: the mustard seed project.

From a Buddhist perspective, grief becomes complicated because mourners have trouble accommodating the reality of impermanence in the face of deep and unwelcome change, as they struggle to make sense of the "event story" of their loss and to revise their life story and identity accordingly. Joining this perspective with a constructivist emphasis on grieving as meaning reconstruction, we developed a distinctive group intervention to help people reflect on the natural conditions of impermanence and limitation in a compassionate environment in which they were encouraged to cultivate a new self-narrative in the wake of loss. Integrating meditative interludes, dyadic sharing, dharma lessons, and informal didactics on the human quest for meaning, we used expressive arts exercises to engage the existential dilemmas of loss from a self-distancing perspective. Evidence from an open trial on 41 participants in 2 groups documents that the intervention is both feasible and acceptable to clients, and that they display significant decreases in grief related suffering, and corresponding increases in meaning making and personal growth, across the brief course of the workshop experience.

Inventory of complicated spiritual grief: development and validation of a new measure.

Although spirituality often has been associated with better outcomes following bereavement, it can be significantly challenged by loss as well. Studies have shown that some bereaved individuals suffer profoundly not only in relation to the death of their loved one but also in their relationship with God and their faith community, a condition known as complicated spiritual grief (CSG). However, to date, in the absence of a simple, multidimensional, and well-validated measure of spiritual crisis following loss, investigators have measured CSG with nongrief-specific instruments. In this study, the authors tested the reliability and validity of a newly developed measure of CSG, called the Inventory of Complicated Spiritual Grief (ICSG). With 2 diverse samples of bereaved adult Christians (total n = 304), the authors found that the ICSG had strong internal consistency, and high test-retest reliability for both subscales in a subsample of participants. Analyses of both samples supported a 2-factor model, with one factor measuring Insecurity with God and the other assessing Disruption in Religious Practice. Analyses further supported the convergent and incremental validity of the 18-item ICSG relative to other theoretically similar instruments and measures of poor bereavement outcome, suggesting its usefulness in clinical research and practice.

Complicated spiritual grief I: relation to complicated grief symptomatology following violent death bereavement.

Losing a loved one to violent death has been associated with poor mental health outcomes, including posttraumatic stress disorder, depression, and complicated grief (CG), a protracted, debilitating, and sometimes life-threatening reaction to loss. In addition, recent research suggests that traumatic loss can violate mourners' basic assumptive worldviews, and can precipitate a spiritual crisis following loss, also known as complicated spiritual grief (CSG). The present cross-sectional study investigated these multidimensional outcomes in a diverse sample of 150 grievers. The authors found that (a) violently bereaved individuals reported greater CG and CSG than did individuals bereaved by natural death; (b) CG and CSG were correlated across the larger sample, and yet are theoretically different constructs; and (c) specific cause of death (natural anticipated, natural sudden, homicide, suicide, or fatal accident) differentially predicted levels of CG and CSG. Implications of these findings for a clearer understanding of spiritual coping in the wake of troubling loss are noted, as well as for intervention with mourners struggling with clinical complications.

Complicated spiritual grief II: a deductive inquiry following the loss of a loved one.

Recent studies have revealed an association between complicated grief-a severe, prolonged response to the loss of a loved one-and complicated spiritual grief-a spiritual crisis following loss. Furthermore, bereavement research has benefitted from a number of studies using qualitative inquiry as a means of examining the experiences of individuals grieving a variety of types of losses. However, a gap in the literature remains in terms of the qualitative investigation of spiritual struggle following loss. Thus, using participants' written responses to open-ended questions along with systematic exploration of this topic with a five-member focus group, we designed this qualitative study to better understand the firsthand experiences of bereaved individuals who have suffered a crisis of faith after the death of a loved one. Specifically, our directed content analysis of bereaved focus group members' responses revealed 17 different common and salient themes subsumed in an overarching narrative of resentment and doubt toward God, dissatisfaction with the spiritual support received, and substantial changes in the bereaved person's spiritual beliefs and behaviors. Thus, our study clarified the construct of complicated spiritual grief, and laid the groundwork for development of more specific assessment and treatment of this condition.

Living and dying with dignity in Chinese society: perspectives of older palliative care patients in Hong Kong.

BACKGROUND: the empirical Dignity Model has profoundly influenced the provision of palliative care for older terminally ill patients in the West, as it provides practical guidance and intervention strategies for promoting dignity and reducing distress at the end-of-life. OBJECTIVE: to examine the concept of 'living and dying with dignity' in the Chinese context, and explore the generalisability of the Dignity Model to older terminal patients in Hong Kong. METHODS: using qualitative interviews, the concept of dignity was explored among 16 older Chinese palliative care patients with terminal cancer. Framework analysis with both deductive and inductive methods was employed. RESULTS: the three major categories of themes of the Dignity Model were broadly supported. However, the subtheme of death anxiety was not supported, while two subthemes of generativity/legacy and resilience/fighting spirit manifested differently in the Chinese context. Furthermore, four new emergent themes have been identified. They include enduring pain, moral transcendence, spiritual surrender and transgenerational unity. CONCLUSION: these findings highlight both a cultural and a familial dimension in the construct of dignity, underline the paramount importance of cultural awareness and competence for working with ethnically diverse groups, and call for a culturally sensitive and family oriented approach to palliative care interventions with older Chinese terminal patients.

Dignity amidst liminality: healing within suffering among Chinese terminal cancer patients.

This study critically examines the concepts of dignity and liminality at the end-of life, in an effort to better understand the processes of healing within suffering among Chinese terminal cancer patients receiving palliative care services in Hong Kong. Meaning-oriented interviews were conducted with 18 Chinese terminal patients, aged 44 to 98, to elicit the narratives and stories of their illness experience. All interviews were analyzed using grounded theory and supplemented by ethnographic observations and field notes. Two major themes and eight subprocesses of healing adopted by patients to achieve and maintain dignity were identified: (a) personal autonomy, which encompasses the need to (i) regain control over living environments, (ii) maintain self-sufficiency despite institutional care, (ii) make informed care decisions to reduce sense of burden, and (iv) engage in future planning to create a lasting legacy; and (b) family connectedness, which encompasses the need to (i) maintain close ties with family members to express appreciation, (ii) achieve reconciliation, (iii) fulfill family obligations, and (iv) establish a continuing bond that transcends generations. Implications of these themes for advanced care planning and life review interventions were discussed with the goal of enhancing patient autonomy and family connectedness, and thereby providing structure and meaning for Chinese terminal patients and their families at the end of life.

Reducing the risk of burnout in end-of-life care settings: the role of daily spiritual experiences and training.

OBJECTIVE: Individuals in the helping professions are subject to unique stressors that may lead to burnout, and research has shown that those who work with dying or bereaved individuals might be particularly at-risk. This study explores how factors such as spirituality and level of training might buffer the stress of working with terminally ill clients and their families. METHOD: A total of 80 medical and mental health practitioners attending palliative care seminars were surveyed, with each completing validated measures of daily spiritual experiences and caregiver burnout, as well as assessments of demographic factors, their general education and training experiences specific to working in end-of-life care and bereavement settings. RESULTS: Findings indicate that daily spiritual experiences might mitigate physical, cognitive, and emotional forms of burnout in the workplace. In addition, a negative correlation was found between the amount of end-of-life training received and burnout in the physical and cognitive domains. However, training was not related to professionals' level of emotional exhaustion. SIGNIFICANCE OF THE RESEARCH: Results reinforce a growing literature on the salutary effects of spirituality, and underscore its relevance as one possible form of constructive coping for professionals attending to the needs of the dying and bereaved. The study carries further implications for how the stresses of such work might be ameliorated by enhanced training efforts, as well as creative facilitation of diverse spiritual expressions (e.g., inclusive forms of ritual recognition of loss) in the workplace.