The Study of Security and Separation: An Unexpected Forerunner of Attachment Theory?

John Bowlby's attachment theory has made a lasting contribution to scientific understanding of the nature and the impact of close interpersonal bonds, tracing their influence from early childhood through adulthood and into bereavement. The experience of separation and loss featured powerfully in Bowlby's account of the causes of mental health difficulties. He acknowledged many sources for his ideas. However, one potential intellectual force, namely, that of the eminent philosopher Bertrand Russell, is missing. The association between Bowlby and Russell is highlighted in this essay to illustrate how a monumental theory may emerge from ideas already around during a particular historical period. Scientific and personal features of their lives are explored to shed light on possible influence. Commonalities between their propositions about attachment are described as well as pertinent biographical details. Questions whether Bowlby was aware of Russell's writing on this topic and reasons why Russell's ideas were not acknowledged are considered.

Bereavement in Times of COVID-19: A Review and Theoretical Framework.

A review of the literature on adaptation to bereavement during the COVID-19 pandemic was conducted to assess the current state of knowledge. Scopus, Web of Science and Google Scholar databases were searched for studies published during the first 6 months of the COVID-19 outbreak. 44 articles were included in the review. Narrative synthesis showed that knowledge was largely based on expert assessments of prior bereavement research and professional experience; there is so far absence of empirical evidence linking features of COVID-19 bereavement situations to health outcomes. Severe negative consequences have been consistently predicted by authors. There is still relatively little consideration of positive or compensatory processes or the possibility that these could alleviate the effect of the shocking, traumatic circumstances. With two notable exceptions, there has been lack of attention to the role of theoretical models for guiding research and practice. A theoretical perspective (the Dual Process Model, DPM) was applied to the information derived from the available articles. Two features of the DPM framework illustrated its relevance: 1. It enables systematic assessment of the range of loss- and restoration-related challenges for the bereaved; 2. It speaks for extension of psychotherapeutic intervention to manage secondary, restoration- as well as primary, loss-oriented stressors; studies have demonstrated that this may increase the effectiveness of intervention. Directions for future research and DPM application are suggested.

Homesickness in social context: An ecological momentary assessment study among 1st-year university students.

Homesickness is common among university students and associated with mental health problems. Most previous studies assessed homesickness as a summary of the past weeks. However, there may be significant fluctuations across situations. At the current residence, homesickness may especially be triggered during (phone) interactions with attachment figures. Dutch and international 1st-year students (n = 92) completed the Utrecht Homesickness Scale and subsequently used a smartphone application to record social interactions for 14 days (ecological momentary assessment [EMA]). For each interaction they reported the social context (e.g. location, contact type) and their affective state, including homesickness. Homesickness in the past weeks and momentary homesickness were both higher in international students than in Dutch students. Feeling homesick was highest at participants' current residency, when interacting with parents, or when using video-chat. When participants felt more homesick, they reported less pleasant and more unpleasant affect. In conclusion, EMA provided insight in cross-situational variations in homesickness.

How Do Drug-Death-Bereaved Parents Adjust to Life Without the Deceased? A Qualitative Study.

Knowledge about how bereaved persons grieve can enhance quality in providing the support and potential services that they need. We aimed to identify ways in which drug-death-bereaved Norwegian parents go on with their lives and what inhibits or promotes adaptation during their grieving. Reflexive thematic analysis was used to analyze 14 semistructured in-depth interviews. We generated three themes: (I) processing grief emotions, (II) proactive coping, and (III) giving and receiving support and assistance. Processing guilt rumination, reflections on blame and a burden of grief emotions characterized grieving early on. Using cognitive strategies and functional-support-giving were found to be the most frequently used strategies. Oscillation between processing stressors and reorientation to the world promoted adjustment to ongoing life. We discuss characteristics of parents who struggle to reorient and outline important implications for policy and practice.

Cremation and Grief: Are Ways of Commemorating the Dead Related to Adjustment Over Time?

Funeral services are known to serve multiple functions for bereaved persons. There is also a common, intuitively reasonable assumption of positive associations between engaging in funeral activities and adjustment to bereavement. We examined whether restricting ceremonial cremation arrangements to a minimum has a negative association with grief over time. Bereaved persons in the United Kingdom completed questionnaires 2 to 5 months postloss and again a year later (N = 233 with complete data; dropout = 11.4%). Neither type nor elaborateness of the cremation service, nor satisfaction with arrangements (typically high), emerged as significantly related to grief; no major subgroup differences (e.g., according to income level) were found. Results suggested that it does not matter to grief whether a more minimalistic or elaborate funeral ceremony was observed. We concluded that the funeral industry represented in this investigation is offering bereaved people the range of choices regarding cremation arrangements to meet their needs. Limits to generalizability are discussed.

Community-based counseling reaches and helps bereaved people living in low-income households.

OBJECTIVE: Poverty is related to increased grief-related mental health problems, leading some to suggest bereavement counseling should be tailored to income. However, information about accessibility and effectiveness of such counseling programs serving low-income households is scarce. This longitudinal study therefore investigated the association between poverty and complicated grief (CG), and the effectiveness of a community-based bereavement counseling program in serving low-income households. METHODS: Two hundred eighty-eight participants (75% female) were enrolled. Loss-related and demographic variables were assessed at baseline. Regression analyses were used to investigate household income as a predictor of CG, and examine bereavement counseling effectiveness by comparing CG symptom change across three household income categories across three time-points: baseline (T1), T1 + 12 months (T2), and T1 + 18 months (T3). RESULTS: Of all participants, 35.8% reported below poverty-threshold income, twice the general population's rate. Multiple regression analysis indicated poverty-threshold income was a predictor of CG symptoms over and above demographic and loss-related characteristics. Three-way interaction analysis detected a significant treatment effect for study condition across time, but no differences in treatment effects across income. CONCLUSION: Lower household income was associated with higher CG symptoms. Since income did not predict differential treatment response, community-based bereavement counseling appeared no less efficacious for members of low-income households. Clinical or methodological significance of this article: While previous research has indicated low income may be a risk factor for mental health problems after bereavement, and it has therefore been suggested bereavement counseling should be tailored to income, no study to date has investigated the need for such tailoring. This controlled, longitudinal treatment study fills this gap in knowledge. Main findings are that low income is a key predictor of complicated grief symptoms. The study also shows that the effectiveness of one-to-one bereavement counseling does not appear to differ according to income level.

Guilt in bereavement: Its relationship with complicated grief and depression.

This study investigated the relationship between guilt and well-being of bereaved persons, and explored potential differences in the associations between guilt-complicated grief (CG) and guilt-depression. In total, 1358 Chinese bereaved adults were recruited to fill out questionnaires. Participants (N = 194) who had been bereaved within 2 years of the first survey, filled out the same questionnaires 1 year later. Higher guilt was associated with higher degrees of both CG and depression. The level of guilt predicted CG and depression symptoms 1 year later. Bereavement-related guilt has a closer association with CG than depression. Responsibility guilt, indebtedness guilt and degree of guilt feeling are more prominent aspects of guilt in CG than in depression. These findings demonstrate the significant role of guilt (perhaps a core symptom) in mental health of the bereaved, having implications for identifying persons with grief complications and depression.

The Poetry of Grief: Beyond Scientific Portrayal.

To comprehend grief, we need knowledge about the range of diverse reactions incorporated within it. While scientists have documented the phenomena and manifestations following the loss of a loved one in quite some detail, poets can add to our understanding by portraying these vividly, bringing the feelings to life. In this article, I map the array of grief reactions identified in scientific investigations. I then go on to give short, selective illustrations from poetry, ones that have enhanced my own understanding of grief. These choices are naturally influenced by my own preferences; I include those that I find personally appealing and evocative of the multifaceted manifestations of grief. My aim is to demonstrate the value of artistic representation for scientific comprehension.

Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial.

This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling model for adults on reducing complicated grief (CG) symptoms. Participants (N = 344; 79% female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was hypothesized that participants who received intervention would experience a greater decline in CG levels immediately following the intervention compared to the control participants, but the difference would diminish at follow-up (due to relapse). Data were collected via postal questionnaire at 3 time points: baseline (T), post-intervention (T + 12 months), and follow-up (T + 18 months). CG, post-traumatic stress, and general psychological distress were assessed at all time points. Multilevel analyses controlling for relevant covariates were conducted to examine group differences in symptom levels over time. A stepwise, serial gatekeeping procedure was used to correct for multiple hypothesis testing. A main finding was that, contrary to expectations, counselling intervention and control group participants experienced a similar reduction in CG symptoms at postmeasure. However, intervention participants demonstrated a greater reduction in symptom levels at follow-up (M = 53.64; d = .33) compared to the control group (M = 62.00). Results suggest community-based bereavement counselling may have long-term beneficial effects. Further longitudinal treatment effect investigations with extensive study intervals are needed.

Cautioning Health-Care Professionals.

Science and practice seem deeply stuck in the so-called stage theory of grief. Health-care professionals continue to "prescribe" stages. Basically, this perspective endorses the idea that bereaved people go through a set pattern of specific reactions over time following the death of a loved one. It has frequently been interpreted prescriptively, as a progression that bereaved persons must follow in order to adapt to loss. It is of paramount importance to assess stage theory, not least in view of the current status of the maladaptive "persistent complex bereavement-related disorder" as a category for further research in DSM-5. We therefore review the status and value of this approach. It has remained hugely influential among researchers as well as practitioners across recent decades, but there has also been forceful opposition. Major concerns include the absence of sound empirical evidence, conceptual clarity, or explanatory potential. It lacks practical utility for the design or allocation of treatment services, and it does not help identification of those at risk or with complications in the grieving process. Most disturbingly, the expectation that bereaved persons will, even should, go through stages of grieving can be harmful to those who do not. Following such lines of reasoning, we argue that stage theory should be discarded by all concerned (including bereaved persons themselves); at best, it should be relegated to the realms of history. There are alternative models that better represent grieving processes. We develop guidelines to enhance such a move beyond the stage approach in both theory and practice.

Telephone versus in-person intake assessment for bereavement intervention: Does efficiency come at a cost?

Standardized, evidence-based risk assessment is an important component in providing effective bereavement care. E-health intake assessments have been offered alongside or instead of in-person assessments, although evidence concerning the equivalence of assessment results is lacking. This article examines differences between a semistructured intake assessment for grief intervention conducted over the telephone (n = 330) and in-person (n = 115). Differences in scores and clinical implications were evaluated. Although composite assessment scores were lower in the telephone condition, further examination revealed this occurred in the semistructured assessment of risk of complications, not the structured grief symptom assessment. Implications for care provision are discussed.

On the Classification and Reporting of Prolonged Grief: Assessment and Research Guidelines.

LEARNING OBJECTIVES AFTER PARTICIPATING IN THIS CME ACTIVITY, THE PSYCHIATRIST SHOULD BE BETTER ABLE TO: • Explain the steps required for diagnosis of mental disorders in diagnostic handbooks.• Identify current procedures for classifying and reporting prolonged grief disorder. ABSTRACT: Prolonged grief disorder (PGD) was added to the 11th edition of the International Classification of Diseases in 2018 and to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders in its 2022 text revision. Thus, reporting and classifying PGD according to established guidelines has become fundamental for scientific research and clinical practice. Yet, PGD assessment instruments and criteria are still being developed and debated. The purpose of this article is to examine the adequacy of current procedures for classifying and reporting PGD in research and to suggest guidelines for future investigation and dissemination of knowledge. We outline the standard steps required for diagnosis and assessment of a mental disorder (notably, the administration of clinical interviews). In order to illustrate reporting about the presence/prevalence of PGD in recent scientific articles, we conducted a search of Scopus that identified 22 relevant articles published between 2019 and 2023. Our review of the literature shows that standard classification procedures are not (yet) followed. Prevalences of PGD are based on self-reported symptomatology, with rates derived from percentages of bereaved persons reaching a certain cutoff score on a questionnaire, without clinical interviewing. This likely results in systematic overestimation of prevalences. Nevertheless, the actual establishment of PGD prevalence was often stated in titles, abstracts, and results sections of articles. Further, the need for structured clinical interviews for diagnostic classification was frequently mentioned only among limitations in discussion sections-but was not highlighted. We conclude by providing guidelines for researching and reporting self-reported prolonged grief symptoms and the presence/prevalence of PGD.

Partner-oriented self-regulation among bereaved parents: the costs of holding in grief for the partner's sake.

Bereavement research has focused on individual rather than interdependent processes in coping with loss. Yet bereavement takes place in a social context, and relationship partners are likely to influence each other's grieving process. We examined the impact of a dynamic, interpersonal phenomenon, partner-oriented self-regulation (POSR): the avoidance of talking about loss and remaining strong in the partner's presence to protect the partner. Two hundred nineteen couples who had lost a child participated 6, 13, and 20 months after their loss. Consistent with predictions, results showed that one partner's POSR was associated not only with an increase in his or her own grief, but also with an increase in the other partner's grief. These relationships persisted over time: Self-reported and partner-reported POSR predicted later grief. These results are paradoxical: Although parents try to protect their partners through POSR, this effort has the opposite of the desired outcome. These findings underline the importance of further investigating interpersonal dynamics of coping with bereavement.

Restoration-oriented stressors of bereavement.

BACKGROUND AND OBJECTIVES: The Dual Process Model of Coping with Bereavement holds that bereaved people who respond flexibly to loss-oriented stressors (i.e., relating to the loss; to the deceased person) and restoration-oriented stressors (i.e., secondary to loss; daily-life changes, taking on new roles) adapt better to bereavement. Despite growing interest in the Dual Process Model, systematic analyses of the prevalence, characteristics, and correlates of restoration-oriented stressors are lacking. Therefore, we aimed to chart restoration-oriented stressors and their relationship with post-loss adaptation. DESIGN AND METHODS: A community sample of 181 bereaved adults (63% women) completed the 20-item expert-construed Restoration-Oriented Stressors Inventory (ROSI) and questionnaires assessing background characteristics, worry, and prolonged grief and depression symptoms. RESULTS: Main findings were that younger people, and those who lost a parent, partner, or child (vs. other relationship) experienced more restoration-oriented stressors and appraised these as more stressful. Stressors' perceived stressfulness, but not their quantity, related positively to worry. Perceived stressfulness predicted prolonged grief and depression symptoms beyond background characteristics, worry, and the number of stressors. CONCLUSION: Restoration-oriented stressors and their appraisal vary and relate to coping and post-loss mental health. Future research should clarify temporal interrelations between stressors, coping mechanisms, and outcomes.

A systematic review of loneliness in bereavement: Current research and future directions.

Bereaved people suffer from loneliness and loneliness is associated with poor mental health. In this study, this topic is reviewed. An agenda is suggested for future research. Research that is theory-driven, addresses measurement consistency, correlates of loneliness in bereaved and non-bereaved, and treatment is necessary for prevention and intervention.

Stages of Grief Portrayed on the Internet: A Systematic Analysis and Critical Appraisal.

Kübler-Ross's stage model of grief, while still extremely popular and frequently accepted, has also elicited significant criticisms against its adoption as a guideline for grieving. Inaccurate portrayal of the model may lead to bereaved individuals feeling that they are grieving incorrectly. This may also result in ineffectual support from loved ones and healthcare professionals. These harmful consequences make the presentation of the five stages model an important area of concern. The Internet provides ample resources for accessing information about grief, raising questions about portrayal of the stages model on digital resources. We therefore conducted a systematic narrative review using Google to examine how Kübler-Ross's five stages model is presented on the internet. We specifically examined the prominence of the model, whether warnings, limitations and criticisms are provided, and how positively the model is endorsed. A total of 72 websites were eligible for inclusion in the sample. Our analyses showed that 44 of these (61.1%) addressed the model, indicating its continued popularity. Evaluation scores were calculated to provide quantitative assessments of the extent to which the websites criticized and/or endorsed the model. Results indicated low criticalness of the model, with sites often neglecting evaluative commentary and including definitive statements of endorsement. We conclude that such presentation is misleading; a definitive and uncritical portrayal of the model may give the impression that experiencing the stages is the only way to grieve. This may have harmful consequences for bereaved persons. It may alienate those who do not relate to the model. Presentation of the model should be limited to acknowledging its historical significance, should include critical appraisal, and present contemporary alternative models which better-represent processes of grief and grieving.

Emotion Regulatory Strategies in Complicated Grief: A Systematic Review.

Prolonged grief disorder, characterized by severe, persistent, and disabling grief, has recently been included in the International Classification of Diseases-11 (ICD-11). Emotional disturbances are central to such complicated grief responses. Accordingly, emotion regulation is assumed critical in the development, persistence, and treatment of complicated grief. Yet, a comprehensive review on this topic is lacking. We conducted a systematic review (PROSPERO: CRD42017076061) searching PsycInfo, Web of Science, and PubMed to identify quantitative research examining relationships between emotion regulation and complicated grief. Sixty-four studies on 7,715 bereaved people were identified, focusing on a variety of emotion regulation strategies (i.e., experiential avoidance, behavioral avoidance, expressive suppression, rumination, worry, problem solving, cognitive reappraisal, positive thought, and mindfulness). Our synthesis showed strong evidence that experiential avoidance and rumination play a role in the persistence of complicated grief. More generally, surveys support positive associations between putative maladaptive emotion regulation strategies and complicated grief, and negative associations between putative adaptive emotion regulation strategies and complicated grief. Laboratory research yielded mixed results. Emotion regulation is critical in complicated grief, and in particular experiential avoidance and rumination form important targets in complicated grief treatments. We advise expanding current knowledge, by employing more advanced, intensive data collection methods and experiments across diverse samples. Increasing knowledge in this domain will improve clinical practice.