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.

Secondary traumatic stress among pediatric nurses: Relationship to peer-organizational support and emotional labor strategies.

BACKGROUND: Even though the cost of caring is acknowledged in multiple helping professions, research into secondary traumatic stress in pediatric nursing remains limited. This study aimed to determine the prevalence of secondary traumatic stress among pediatric nurses and examine its correlation with demographics, perceived organizational support, peer support, and emotional labor strategies. DESIGN AND METHODS: A total of 186 nurses working in a pediatric hospital completed questionnaires addressing secondary traumatic stress, perceived organizational support, peer support, and emotional labor strategies. Through correlational and mediation analyses, we explored the relationships between the study variables. RESULTS: Approximately 77.8% of the pediatric nurses surveyed exhibited moderate to severe secondary traumatic stress. Notably, the level of secondary traumatic stress did not correlate with demographic variables. Increased peer support was significantly associated with a heightened use of all emotional labor strategies (surface acting, deep acting, and natural expression) and with elevated levels of secondary traumatic stress. However, surface acting was the sole mediator of this relationship. Conversely, greater perceived organizational support correlated with decreased levels of surface acting and secondary traumatic stress, with surface acting serving as the mediator. CONCLUSIONS: Pediatric nurses are greatly impacted by secondary traumatic stress. Enhancing organizational support and carefully assessing peer support can reduce this, by decreasing nurses' need to suppress or feign genuine emotions. PRACTICE IMPLICATIONS: To enhance nurses' psychological well-being, healthcare institutions should raise awareness of secondary traumatization and foster a supportive organizational environment that prioritizes effective team emotional support and evaluates collegial emotional labor.

An Analysis of Factors Predicting Post-Traumatic Stress Disorder and Grief Following Comrade Loss.

This study explored how "inhibiting factors" associated with military-bereavement impact combatants' psychological sequelae following comrade loss. One hundred six eligible Israeli combat male-soldiers completed the Texas-Revised-Inventory of Grief, the post-traumatic-stress-disorder symptoms scale (PSS), the Male Role Norms Scale, the Social Acknowledgment Questionnaire, and a scale assessing Military Encouragement to Grieve (MEG-8). Time since loss had no impact on soldiers' levels of PSS or prolonged grief. Regression analysis indicated that higher masculinity-perception and disapproval from the family predicated higher PSS, above and beyond grief. Conversely, lower disapproval from the family, and higher disapproval from the general community, predicted higher grief, above and beyond PSS. Also, military encouragement significantly mediated the positive relationship between masculinity and sense of social-recognition. The results show how inhibiting factors contribute differently to the perpetuation of PSS and grief. This interplay sheds light on soldiers' "external" and "internal" loss processes of traumatic bereavement. The practical implications to treatment are also discussed.

Perfectionism, Big Five and biopsychosocial functioning among parents of children with and without acquired brain injury (ABI).

BACKGROUND AND OBJECTIVE: Personality factors are often investigated in the context of parenting but are rarely studied in relation to coping with child disabilities like pediatric acquired brain injury (pABI). This study (1) compares Biopsychosocial functioning (BPSF), Big Five personality traits, and dimensions of perfectionism of parents of children with and without pABI, and (2) examines the role personality factors play in parental BPSF in each group. METHOD: 57 parents of children who sustained a significant pABI and 50 parents of typically developing children participated in this cross-sectional study. Parents completed scales measuring Multidimensional Perfectionism, Big Five inventory, and BPSF. RESULTS: Among the pABI group, multivariate analysis indicated significantly poorer BPSF, higher levels of neuroticism, socially prescribed perfectionism, and lower levels of openness, than controls. Regression analysis showed that personality explained 60.5% of the variance in parental BPSF post pABI. In both samples, neuroticism and socially prescribed perfectionism appeared as two prominent personality factors with a significant negative effect on parental BPSF, while self-perfectionism appeared prominent only in the pABI group, indicating a significant positive effect. IMPLICATIONS: pABI may result in changes to parents` personality. Personality characteristics significantly contribute to parental BPSF post-injury and should be addressed in clinical practice.

"Crying in My Uniform, For Sure": A Qualitative Thematic Analysis of Loss and Grief Among Soldiers After Losing a Comrade in Combat.

Recent studies investigate grief among soldiers who experienced combat loss, but little research exists on the qualitative lived experience of such an event. In this study, semi-structured interviews were conducted with soldiers (n = 19) who lost a comrade (3-21 years ago) to delve into their bereavement process. The reflexive thematic analysis of soldiers' accounts identified six main themes: (1) an unexpected and shattering experience; (2) emotional dissociation; (3) detachment from the outside world; (4) group formation; (5) accommodating the bereaved family; and (6) life-long impact. These themes were positioned on four distinct circles relating to the self and the surrounding social systems, indicating how soldiers' grief unfolds and remains encapsulated and disenfranchised. The findings emphasize the value of peer support groups that should be facilitated and encouraged by official bodies-even years after-as part of providing social recognition.

"Mind the gap": Exploring pediatric nurses` perceptions of the theory and practice of caring for children and families.

PURPOSE: To investigate how pediatric nurses interpret and conceptualize theoretical underpinnings and daily practice scenarios pertaining to their role in pediatric care. DESIGN AND METHODS: 139 pediatric nurses completed a survey in which they were asked to endorse to what extent practices related to pediatric concepts are expected from their role ("Expected") or are actually implemented in their clinical work ("Actual"). Survey items were derived from a nursing textbook that outlines the theoretical tenets of the "art of pediatric nursing", along with scenarios and conflicts encountered in everyday practice, covering family-child centered care, child growth and development, and emotional boundaries. RESULTS: In both Expected and Actual practices, the highest level of endorsement was for items focused on core elements of family-centered care (80-96%), and moderate-low endorsement levels were observed for items related to therapeutic relationship management and emotional boundaries. A factor analysis yielded 12 factors representing themes related to pediatric nursing. However, the division of items per factor indicated diffusion between key concepts and a discrepancy between theory and practice, especially in regard to maintaining emotional separateness and objectivity, advocacy, managing conflicts within the nurse-child-family triad, and navigating oneself boundaries. CONCLUSIONS: Nurses' ability to manage and contain various types of unclear boundaries is crucial for optimal care provision when working with children and families. PRACTICE IMPLICATION: Variability in nurses' theoretical role-perception and practical care provision is largely attributed to the way they navigate various ambiguous boundaries in practice and this could be a focal point in educational programs and on-the-job training.

"Concurrent Ropes and Ladders": Mapping and Conceptualizing the Emotional Loss Experience of Parents Following Pediatric Acquired Brain Injury.

This grounded theory study aims to map, conceptualize, and theorize the emotional loss experienced by parents following their child's pediatric acquired brain injury (pABI). Data were obtained from 47 semi-structured interviews conducted with parents (72% mothers) at least 1 year following pABI. The study's theory of "concurrent ropes and ladders" emerged from a process of initial in vivo coding followed by focused and thematic coding. Codes were consolidated into five thematic categories capturing parents' emotional continuous loss experience: (a) comparing life before and after, (b) struggling to construct new realities, (c) recognizing instability and permanency, (d) adjusting and readjusting, and (e) grieving as an emotional shadow. These categories are at work simultaneously in parents' accounts, thus supporting a model of dynamic concurrency within and across their lived experiences. Recommendations for practitioners were derived from the theory to support parents' emotional coping with living loss throughout the chronic stage.

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.

Factors associated with parental grief reaction following pediatric acquired brain injury.

The present study investigated factors associated with parental grief reaction (PGR) following pediatric acquired brain injury (ABI), and compared PGR to the one exhibited following child death. Fifty-seven parents of 51 children (aged 3-18) whose ABI occurred 1-14 years before participation, completed the multi-scale Two-Track Bereavement Questionnaire; a socio-demographic questionnaire; and a scale assessing perceived behavioural changes in the child. Results from regression analysis indicated that time since injury had no impact on parents' grief other than having an adverse impact on their overall coping and functioning; A higher amount of weekly caring hours predicted only a greater traumatic perception of the loss; Older children's ages but mostly greater parental-perceived behavioural changes, predicted greater PGR on most scales. PGR was compared with the pre-existing data of bereaved parents who completed the same grief questionnaire. Although grief response patterns and intensity were similar in both groups, significant differences were found on scales assessing the continuing bond with the child: relational active grief, close and positive relationship, and conflictual relationship. Our findings indicate that parental grief is multi-dimensional following pediatric ABI and illuminate the interplay between elements characterizing parents' nonfinite vs. finite loss experience.

Self-efficacy and acceptance of disability following mild traumatic brain injury: A pilot study.

Recovery from mild traumatic brain injury (mTBI) and regaining emotional equilibrium afterward can take much longer than the typical three months. Recent works attribute persisting complaints to psychological factors, primarily the negative perception of mTBI. However, research has yet to demonstrate how self-beliefs concerning capability are linked to perception and ability to accept injury. The objective of this study was to investigate how perceived general self-efficacy (GSE) and acceptance of disability (AD) relate to emotional outcome following mTBI. Thirty individuals aged 21-57, all of whom were at least three-month post diagnosis of mTBI, underwent a psychiatric clinical interview assessing depression, post-traumatic stress disorder (PTSD), and quality of life (QoL), and completed self-report scales to evaluate psychological factors. Scores on AD, depression, and QoL for most life domains were significantly lower and worse than among the normative population. Pearson coefficients indicated significant correlations between psychological factors and emotional outcome. Mediation analysis showed a significant role of AD in mediating the correlation between GSE and depression/general QoL, irrespective of PTSD. Low self-efficacy accentuates negative perception of the injury which, in turn, leads to poor emotional outcomes post mTBI. Therefore, AD should become the focus of therapeutic interventions.

Locked-in your heart-shaped box: Familial-role and attachment orientation as predictors of grief in prolonged disorders of consciousness vs. death.

Death or prolonged disorders of consciousness (DOC) of a loved one are both considered relational-losses that severely disrupt attachment-bonds. Grief in both conditions was compared by exploring the impact of familial-role and attachment-orientation. In DOC, caregivers' grief was found significantly intensified relative to Death. Familial-role impacted grief in both conditions alike, with partners' heightened grief in DOC reflecting the complexity of their stagnant bonds. In Death, avoidance-attachment mitigated grief, while in DOC anxiety-attachment accentuated grief, we suggest that while physical-separation in death facilitates the modification of continuing attachment-schema, in DOC, modification may be required while the patient is still alive.

Exploring the role of perceived vs. observed behavioral outcomes in parental grief reaction following pediatric acquired brain injury.

BACKGROUND: Pediatric acquired brain injury may result in a significant gap between the "pre" and "post-injury" child. OBJECTIVE: We aimed to quantitatively explore the mechanism underlying parents' loss experience by examining the mediating role of behavioral outcomes (observed-problems and perceived-change) in the relationship between injury severity and grief. METHOD: The study employed a cross-sectional retrospective design and comprised 40 parents of children (aged 3-18 years) with moderate-severe brain injury. Data for each parent included an adapted version of the Two-Track Bereavement Questionnaire and Socio-demographics; Data for each child included the child's Information Processing Speed Index; the Child Behavioral Checklist and Parental Perception of Behavioral Changes scale. RESULTS: Slowed information processing speed was significantly associated with elevated ratings on both measures of behavioral outcomes and with intensified grief. Mediation analyses revealed that parental perceived behavioral change, significantly mediate the relationship between information processing speed and grief; the Child Behavioral Checklist total score also mediated the same relationship but only in 90% confidence interval. CONCLUSIONS: Findings reveal the adverse impact of behavioral outcomes on grief and suggest parents' loss experience to be stemming primarily from their subjective perception over their "changed-child", rather than the observed problems. Implications for clinical practice are discussed.

Partially dead, partially separated: establishing the mechanism between ambiguous loss and grief reaction among caregivers of patients with prolonged disorders of consciousness.

OBJECTIVES:: To trace the psychological mechanism underlying caregivers' emotional experience in prolonged disorders of consciousness, by examining the mediating role of boundary ambiguity in the relationship between ambiguous loss and grief. DESIGN:: Cross-sectional design. SETTING:: The Respiratory Rehabilitation Division of a long-term medical and rehabilitation institute. SUBJECTS:: A total of 64 primary caregivers (69% female) of patients in a vegetative state ( n = 49) or minimally conscious state ( n = 15), with a mean age of 55.5 (SD = 12.3) years. Participants were mostly the patient's children (62%) or partners (27%). The mean caregiving duration was 4.9 (SD = 5.1) years. MAIN MEASURES:: The Boundary Ambiguity Scale, the Revised Need for Closure Scale, an adapted version of the multifactor Two-Track Bereavement Questionnaire, and a sociodemographic questionnaire, which included items regarding caregiving: frequency of visits and perception of the patient's psychological presence. RESULTS:: (1) Caregivers' grief scores (total TTBQ: mean = 2.97; SD = 0.55) did not significantly differ from those exhibited by a normative bereavement sample. (2) Time since injury did not affect caregivers' grief scores (three-year cut-point; P > .05). (3) Mediation analyses revealed that boundary ambiguity (mean = 34.03; SD = 7.55) significantly mediates the relationship between need for closure ( B = .11; confidence interval (CI) = .04-.23) and grief; frequency of visits ( B = .05, CI = .02-.10) and grief and perception of psychological presence ( B = .26, CI = .00-.61) and grief in three separate models. CONCLUSION:: Ambiguity concerning relational boundaries hinders caregivers' ongoing grief reaction and impedes their ability to integrate the loss. High frequency of visits, belief in the patient's psychological presence and difficulties in tolerating uncertainty are all clinical manifestations of caregivers' entangled experience.

Basal ganglia play a unique role in task switching within the frontal-subcortical circuits: evidence from patients with focal lesions.

The performance of patients with lesions involving the basal ganglia (BG) was compared to that of patients with prefrontal (PFC) lesions, thalamic (TH) lesions, and age-matched controls in order to examine the specific role of the BG within the frontal-subcortical circuits (FSCC) in task switching. All the BG patients and none of the other participants showed a marked increase in error rate in incongruent trials where correct responses depended upon the choice of the correct task rule. Some BG patients erred in failing to switch tasks and others failed despite their attempt to switch tasks. Additionally, reaction time results indicate abnormal response repetition effects among the BG patients; failure in benefiting from advance task information among all the patients; and increased task mixing costs following PFC lesions. The authors conclude that although the frontal-subcortical circuits jointly determine some behaviors (such as benefiting from preparation), the BG play a unique role within the FSCC in action selection and/or the inhibition of irrelevant information.

Is there a general task switching ability?

Participants were tested on two analogous task switching paradigms involving Shape/Size tasks and Vertical/Horizontal tasks, respectively, and three measures of psychometric intelligence, tapping fluid, crystallized and perceptual speed abilities. The paradigms produced similar patterns of group mean reaction times (RTs) and the vast majority of the participants showed switching cost (switch RT minus repeat RT), mixing cost (repeat RT minus single-task RT) and congruency effects. The shared intra-individual variance across paradigms and with psychometric intelligence served as criteria for general ability. Structural equations modeling indicated that switching cost with ample preparation ("residual cost") and mixing cost met these criteria. However, switching cost with little preparation and congruency effects were predominantly paradigm specific.

Task alternation cost without task alternation: measuring intentionality.

A behavioral dissociation between intention and action was demonstrated by patient AF who sustained damage to the left-hemisphere including the basal ganglia. The patient was tested in a task switching paradigm involving two choice reaction-time tasks: SIZE (small/large) and SHAPE (circle/square). The last block in each of the two sessions involved only one task. AF switched tasks reasonably well in the first 40 trials, but unlike her matched control group, in all the remaining trials when two tasks were involved, she performed only the SIZE task. Interestingly, although no task switching took place, AF continued to demonstrate behaviorally her intention to switch tasks. First, she exhibited "task alternation cost", poorer performance relative to instructed single-task trials. Second, shifting to an instructed single-task condition was accompanied by an initial response slowing, indicating a change in goal-state. Finally, when instructed to switch tasks, AF demonstrated the "task-congruency effect", indicating interference from the instructed but competing stimulus-response mapping. Two groups of university students were instructed to perform only the SIZE task, after initial switching, either while ignoring the SHAPE cues ("Ignore") or while being prepared for the SHAPE task only when the cue appeared in red, which never happened ("Attend color"). AF's performance resembled the one of the "Attend color" group and not the "Ignore" group. The results indicate that AF had a partially activated intention to switch tasks. The implications to intentionality and task switching theory are discussed.