The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review.

Bereaved individuals are increasingly considered at risk for negative psychological and physiological outcomes. Visual art modalities are often incorporated into grief therapy interventions, and clinical application of art therapy techniques with the bereaved has been widely documented. Although clinicians and recipients of these interventions advocate for their helpfulness in adapting to bereavement, research investigating the efficacy of visual art modalities has produced equivocal results and has not yet been synthesized to establish empirical support across settings. Accordingly, this review critically evaluates the existent literature on the effectiveness of visual art modalities with the bereaved and offers suggestions for future avenues of research. A total of 27 studies were included in the current review. Meta-analysis was not possible because of clinical heterogeneity and insufficient comparable data on outcome measures across studies. A narrative synthesis reports that therapeutic application of visual art modalities was associated with positive changes such as continuing bonds with the deceased and meaning making. Modest and conflicting preliminary evidence was found to support treatment effectiveness in alleviating negative grief symptoms such as general distress, functional impairment, and symptoms of depression and anxiety.

The role of religious affiliation in Christian and unaffiliated bereaved emerging adults' use of religious coping.

Though research on bereavement has grown, few studies have focused on emerging adults. To add to the literature, the authors administered the RCOPE to a sample of bereaved college students (analyzed sample N = 748) and explored the relationship between self-reported religious affiliation and religious coping strategies used and endorsed as "most helpful." Results highlight the rich topography of bereavement previously unexamined in understudied populations (i.e., emerging adults, religiously unaffiliated). Specifically, the Christians/affiliated used "negative" religious coping strategies most often, yet identified "positive" strategies as "most helpful," whereas the unaffiliated instead used "positive" strategies most often and identified "negative" strategies as "most helpful."

Development of a Short-Form of the RCOPE for Use with Bereaved College Students.

Bereavement is being increasingly recognized as a key issue in college populations (Balk in Mortality 2:207-220, 1997; Balk et al. in Death Stud 34:459-468, 2010). However, there is currently a dearth of research on the impact that the loss of a loved one has on college students and the ways that college students cope during the grieving process. This lack of research, particularly among younger groups, is problematic as researchers have shown that emerging adults experience a surprisingly high number of losses and are an at-risk group for poor post-loss outcomes (Servaty-Seib and Taub 2010; Servaty-Seib and Hamilton 2006; Arnett in Am Psychol 55(5):469, 2000). Religion is a common way that individuals cope with bereavement (Frantz et al. in Pastor Psychol 44(3):151-163, 1996) and may also be commonly used by college students to manage everyday stress (Merrill et al. 2009). The RCOPE (Pargament et al. in J Clin Psychol 56(4):519-543, 2000; J Health Psychol 9:713-730, 2004) is a frequently used measure of religious coping that has recently been evaluated for use with a bereaved undergraduate population. Lord and Gramling (2014) examined the factor structure of the RCOPE and concluded that overlap between the positive and negative religious coping subscales when used with a bereaved undergraduate sample detracted from the predictive utility of the instrument. The researchers provided evidence for the use of a new 2-factor, 39-item version of the RCOPE with the bereaved college student population. The current study replicated Lord and Gramling (2014) with a large follow-up sample of bereaved undergraduates. Participants (N = 677) consisted of individuals who had lost a loved one within the past 2 years, had a mean age of 19.1, and were predominantly female (62%) underclassmen (84% freshman or sophomore status). A majority of participants (68%) were identified as Christian. Exploratory factor analyses closely mimicked the results of the previous study, and the number of items was further reduced in order to provide a briefer version of the scale for use in future research. Hierarchical regression models demonstrated discriminate, convergent, and predictive validity of the instrument.

Patterns of religious coping among bereaved college students.

Contemporary research has suggested that bereavement is a paramount issue in college populations, a group which has historically been underrepresented in grief research (Balk. in Death studies 25:67-84, 2001; Balk et al. in Death Studies 34:459-468, 2010). Indeed, there has been a call to generate new research on grief with specific populations and age groups (Center for the Advancement of Health. in Death Studies 28:568-575, 2004). Religion is often described as a primary way that individuals cope with bereavement in particular (Frantz et al. in Pastor Psychol 44(3):151-163, 1996) and has been shown to effect college student reactions to stress in general (Merrill et al. in Mental Health, Religion & Culture 12(5):501-511, 2009). The RCOPE (Pargament et al. in J Clin Psychol 56(4):519-543, 2000, J Health Psychol 9:713-730, 2004) is a frequently used measure of religious coping, but has not been evaluated with a bereaved undergraduate population. Given that emerging adulthood is a critical developmental phase of religious identity (Fowler. in New Directions for Child Development 3(52):27-45, 1991), the current study examined the factor structure of the RCOPE within a sample of bereaved college students. An exploratory factor analysis was performed, which approximated the factor structure proposed by Pargament et al. (J Clin Psychol 56(4):519-543, 2000). However, a high correlation between the positive and negative religious coping subscales (r = 0.71) detracted from the predictive utility of Pargament et al.'s (2000) two overarching subscales. Therefore, an exploratory factor analysis with an orthogonal rotation was used to identify two uncorrelated subscales (adaptive religious coping and maladaptive religious coping). This new two-factor, 39-item version of the RCOPE was found to demonstrate good internal consistency (α > 0.8) as well as convergent and discriminant validity. The interaction between religious coping strategies and core beliefs about the predictability of the world is explored, and directions for future research and clinical practice are suggested.

Pain coping strategies for tension-type headache: possible implications for insomnia?

STUDY OBJECTIVES: Insomnia has been identified as a risk factor for tension-type headache, although the pathogenesis of sleep disturbance in this population is unclear. The present study examined pain-related self-management strategies in a nonclinical, young-adult sample for preliminary evidence to support a novel hypothesis for the development of insomnia in this population. METHODS: Self-report data on triggers of headache, pain interference with sleep, and pain-related self-management strategies were analyzed for 32 women with tension-type headache and 33 women with minimal pain who served as controls. RESULTS: The results revealed that a significantly greater proportion of the headache group relative to the control group reported sleep problems as a trigger of headaches, stress as a trigger of headache, and going to sleep as a coping strategy for pain. The headache group also reported significantly higher ratings of pain interference with sleep. Going to sleep was the most commonly used self-management strategy (81%) by headache sufferers and also rated as the most effective strategy (5.5 out of 7.0). CONCLUSIONS: These findings suggest that a bidirectional relationship between sleep disturbance and headache is present in this young-adult sample. Furthermore, the frequent use of sleep as a self-management strategy for pain is consistent with the hypothesis that sleep-seeking behavior might be a mediating factor in the development of insomnia among people with tension-type headache. This hypothesis fits within the most widely accepted conceptual model of chronic insomnia and should be further investigated in individuals with both tension-type headache and insomnia.

Catastrophizing and pain-coping in young adults: associations with depressive symptoms and headache pain.

UNLABELLED: Cognitive and behavioral pain-coping strategies, particularly catastrophizing, are important determinants of the pain experience. Most studies of pain-coping are performed in samples of treatment-seeking patients with longstanding pain complaints. Individual differences in pain-coping styles may also significantly affect day-to-day pain and quality of life in nonclinical samples, though this has rarely been investigated. In particular, headache pain is common in the general population, and little is known about how pain-related coping affects pain and quality of life among headache sufferers from a nonclinical setting. In this study, 202 generally healthy subjects were divided into 2 groups, those who reported problem headaches and pain-free control subjects. Reports of pain-related catastrophizing and the use of active pain-coping strategies did not differ between the groups, but differential associations between pain-coping strategies and emotional functioning were observed. Specifically, within the headache group only, those reporting higher levels of pain catastrophizing and lower levels of active pain-coping showed the highest level of depressive symptoms. Further, higher catastrophizing was associated with greater headache pain and pain-related interference. These findings suggest that catastrophizing has little influence on emotional functioning in those without ongoing pain complaints and highlight the importance of coping in modulating the consequences of pain on day-to-day functioning, even in samples from nonclinical settings. Moreover, these findings indirectly suggest that interventions that increase adaptive coping and decrease catastrophizing may help to buffer some of the deleterious functional consequences of headache pain. PERSPECTIVE: This study adds to a growing literature that conceptualizes catastrophizing as a diathesis, or risk factor, for deleterious pain-related consequences. These data suggest that catastrophizing may require the presence of a pain condition before its detrimental effects are exerted.

Psychophysiological responses of female headache sufferers and controls using a picture-viewing paradigm.

Despite the advancement of the biopsychosocial model, the interrelationship between behavioral, emotional, and physiological factors in tension-type headache (TTH) remains unclear. Using a picture-viewing paradigm, the present study investigated differences between females with TTH and controls on physiological reactivity, affective valence and arousal, and oral motor habits. In addition, the concordance between EMG activity and self-reported oral habits (i.e., proprioceptive awareness) and EMG activity and self-reported affect (i.e., affective coherence) were measured using within-subject correlations per individual and then compared between groups. Data were analyzed for 27 TTH sufferers and 27 controls who completed a questionnaire packet followed by a psychophysiological assessment consisting of 3 phases (adaptation, scheduled-viewing, recovery) with EMG activity recorded continuously at 3 sites (frontalis, corrugator, zygomatic). During the scheduled-viewing phase, participants were presented with 24 pictures designed to elicit positive, neutral, and negative affect. Compared to controls, the headache group reported elevations in pain, oral habits, and stress across the 3 phases of the assessment, along with elevations in arousal while viewing the pictures. There were no significant differences between the groups in EMG activity while viewing the pictures. Analyses on concordance revealed partial evidence for poor proprioceptive awareness and affective coherence among the headache group, although the correlations were not significantly different than the control group. These findings suggest that arousal, stress perception, and oral habits may play a role in the pathophysiology of TTH and that within-subject designs should be tested further against group designs when measuring psychophysiological concordance.

EMG reactivity and oral habits among young adult headache sufferers and painfree controls in a scheduled-waiting task.

Previous research has shown that patients with facial pain exhibit a pattern of physiological and behavioral reactivity to scheduled-waiting tasks that may help account for the development of facial pain. The present study extended this line of research by examining the psychophysiological reactivity of headache sufferers in a similar task. A total of 34 frequent headache sufferers screened by International Headache Society (IHS) criteria and 13 painfree controls completed a psychophysiological assessment consisting of 4 phases (adaptation, free-play, scheduled-play, and recovery) that included a scheduled-waiting condition (scheduled-play) designed to produce adjunctive behavior. Masseter and frontalis EMG were measured continuously during each phase and self-reported oral habits and pain ratings were collected following each phase. A significant interaction and group effect was found on frontalis EMG, with the headache group exhibiting elevated EMG levels across the phases, whereas the control group exhibited increasing EMG levels that peaked during the scheduled-play phase. Only a significant phase effect was found on masseter EMG, with the highest EMG levels recorded during the scheduled-play phase for both groups. In addition, a significant phase effect was found on self-reported oral habits data. Overall, these results provide general support for the adjunctive behavior effect, but the predicted difference in magnitude between the groups was not found.

Differences in anger expression between individuals with and without headache after controlling for depression and anxiety.

OBJECTIVE: To evaluate whether anger and anger expression are different between persons with and without headache after controlling for depression and anxiety. BACKGROUND: Persons with headache may experience more problems with anger and its expression when compared with persons without headache. It is important to establish whether differences exist for persons with and without headache on trait anger and anger expression independent of depression and anxiety. To date, however, this issue has received little attention in the empirical literature. The current study measured trait anger, anger-in, hostility, anxiety, and depression among persons with and without headache, and evaluated whether trait anger and anger-in differentiated groups independent of depression and anxiety. METHODS: Participants were 422 adults recruited from a larger study within a university setting. Of those, 171 suffered from headache (mean age, 21 years; 81% were female; 69% were white; mean years with pain, 7.53). Another 251 sex-matched individuals (mean age, 21 years; 81% female; 62% white) met criteria for the headache-free group. Participants provided information regarding their headache characteristics and were administered affective trait measures (Trait version of the State-Trait Anxiety Inventory, Brief Symptom Inventory-Depression), trait anger measures (Trait Anger Scale, Cook-Medley Hostility Scale), and a measure of the extent to which individuals hold their anger in. RESULTS: Multivariate analysis of variance revealed significant differences between the 2 groups (Wilks lambda =.86, P <.001, eta2 =.14). Step-down analysis revealed that even after controlling for all other variables, those in the headache group had higher levels of anger-in (P <.001, eta2 =.08; mean, 18.98 versus 15.68). Trait anger and hostility did not differ between groups after controlling for depression and anxiety. Logistic regression revealed that anger-in contributed most to predicting headache status (P <.001; partial r =.23). CONCLUSIONS: The current findings indicate that persons with headache hold their anger in more than those without headache even after controlling for levels of trait anger, depression, and anxiety. However, after controlling for depression and anxiety, individuals no longer differed on trait anger. Also, anger-in was the strongest predictor of headache. The current findings suggest that holding anger in is more common among headache sufferers. Given recent findings regarding the negative effect of holding anger in among persons with pain conditions, this may be an important factor to evaluate when considering psychological/emotional factors affecting headache.