Associations of religious and existential variables with psychosocial factors and biomarkers of cardiovascular risk in bereavement.

Bereavement increases in prevalence as people age and is associated with multiple psychological and health risks, including cardiovascular risk. Religious and existential variables may play an important role in the health impacts of bereavement. Theorized pathways linking religious and existential variables with health have suggested these associations are due to intermediary psychosocial variables, but have not been tested in bereavement. This research empirically tested these pathways in a bereaved population. In N = 73 adults within 1 year of bereavement (mean age = 64.36), this study examined associations between (1) religious and existential characteristics (religious and spiritual struggles, intrinsic religiosity, and existential quest) and intermediary psychosocial variables (depression, loneliness, and difficulties in emotion regulation), and between (2) intermediary psychosocial variables and bereavement-relevant health outcomes (self-reported health, change in health since last year, grief severity, and cardiovascular biomarkers). Cardiovascular biomarkers (heart rate, heart rate variability, and blood pressure) were collected before, during, and after a laboratory grief recall emotion elicitation. Anticipated associations between self-reported religious and existential characteristics and intermediary variables, and between intermediary variables and self-reported bereavement-relevant outcomes, were consistently observed. However, associations between intermediary variables and cardiovascular biomarkers were largely unobserved. This study examined the role of religious and existential variables in whole-person health after bereavement and is among the first to include biomarkers of cardiovascular risk. Results suggest that although religious and existential variables are associated with important bereavement-related outcomes, these associations may be "skin-deep," and extensions to cardiovascular functioning should be re-examined.

Measuring double awareness in patients with advanced cancer: A preliminary scale development study.

BACKGROUND: Individuals with advanced cancer face the challenge of living meaningfully while also preparing for end of life. The ability to sustain this duality, called "double awareness," may reflect optimal psychological adaptation, but no psychometric scale exists to measure this construct. OBJECTIVES: The purpose of this study was to develop a novel scale to measure double awareness in patients living with advanced cancer. METHODS: Guided by best practices for scale development, this study addresses the first three of nine steps in instrument development, including domain clarification and item generation, establishment of content validity of the items, and pre-testing of the items with patients. RESULTS: Instrument development resulted in a 41-item measure with two dimensions titled "life engagement" and "death contemplation." Items retained in the measure displayed face validity and were found to be both acceptable by patients and relevant to their lived experience. SIGNIFICANCE OF RESULTS: The results of this scale development study will allow for full validation of the measure and future use in clinical and research settings. This novel measure of double awareness will have clinical utility and relevance in a variety of settings where patients with advanced cancer are treated.

A pull to be close: The differentiating effects of oxytocin and grief stimulus type on approach behavior in complicated grief.

Theoretical models of complicated grief (CG) suggest that maladaptive motivational tendencies (e.g., perseverative proximity-seeking of the deceased; excessive avoidance of reminders) interfere with a person's ability to recover from their loved one's death. Due in part to conflicting evidence, little mechanistic understanding of how these behaviors develop in grief exists. We sought to (1) identify behavioral differences between CG and non-CG groups based on approach/avoidance bias for grief-, deceased-, and social-related stimuli, and (2) test the role of the neuropeptide oxytocin in shaping approach/avoidance bias. Widowed older adults with (n = 17) and without (n = 22) CG completed an approach/avoidance task measuring implicit bias for both personalized and non-specific grief-related stimuli (among other stimuli). In a double-blinded, randomized, counterbalanced design, each participant attended both an intranasal oxytocin session and a placebo session. Aims were to (1) identify differential effects of CG and stimulus type on implicit approach/avoidance bias [placebo session], and (2) investigate interactive effects of CG, stimulus type, and oxytocin vs. placebo on approach/avoidance bias [both sessions]. In the placebo session, participants in the non-CG group demonstrated an approach bias across all stimuli. Intranasal oxytocin had an overall slowing effect on the CG group's response times. Further, oxytocin decreased avoidance bias in response to photos of the deceased spouse in the CG group only. Findings support the hypothesis that oxytocin has a differential effect on motivational tendency in CG compared to non-CG, strengthening evidence for its role in CG. Findings also emphasize the need to consider differences in personalized vs. generic stimuli when designing grief-relevant tasks.

Evaluating training needs in clinical psychology doctoral programs.

OBJECTIVE: Advances in clinical psychology must be accompanied by advances in training. This study assessed training content, quality, and needs during clinical psychology doctoral programs among current or past doctoral students. METHODS: Current or past clinical psychology doctoral students (N = 343) completed an anonymous survey assessing training experiences and needs. A descriptive-focused exploratory factor analysis (EFA) also examined whether common subgroups of academic interests emerged. RESULTS: Most participants reported that they sought training beyond required coursework, primarily in clinical training, cultural competency, and professional development, and reported having taken one or more unhelpful course, including discipline-specific knowledge requirements. Descriptive results from the EFA demonstrated common training areas of interest: diversity topics, biological sciences, clinical practice, and research methods. DISCUSSION: This study demonstrates that trainees and early career psychologists are aware of their nuanced and in some cases, unmet training needs. CONCLUSION: This work foregrounds the need to adapt extant training opportunities to support the next generation of clinical psychologists.

The Relationship of Prolonged Grief Disorder Symptoms With Hemodynamic Response to Grief Recall Among Bereaved Adults.

OBJECTIVE: Bereavement is among the most impactful psychosocial stressors for cardiovascular health, and hypertensive episodes accompanying bereavement-related distress are one putative mechanism for this effect. The present study examined hemodynamic responses to the Grief Recall (GR), a promising method for studying the effects of acute grief on cardiovascular function, and the relationship of grief severity to blood pressure (BP) response. METHODS: N = 59 participants within 1 year of the loss of a close loved one completed the GR, a semistructured interview protocol for eliciting bereavement-related distress (a "grief pang") and cardiovascular response. Systolic (SBP) and diastolic BP (DBP) were measured at two time points: a) an attention-control baseline and (2) after a 10-minute GR interview. Baseline versus post-GR SBP and DBP differences (i.e., BP response) were measured. Grief severity was examined as a predictor of SBP and DBP response, as well as BP recovery. RESULTS: SBP and DBP increased significantly after GR (SBP, +21.10 mm Hg; DBP, +8.10 mm Hg). Adjusting for variables relevant to cardiovascular function and bereavement (antihypertensive medication use, days since death, gender, age), grief severity predicted the magnitude of increase after GR in SBP but not DBP. No relationship of grief severity and recovery was observed. CONCLUSIONS: The observed association between hemodynamic response and grief severity suggests a mechanistic contribution from hemodynamic effects of acute grief episodes to the cardiovascular impact of grief. This is the first study to show that increased symptoms of prolonged grief disorder are associated with an elevated SBP response. The GR may have further utility for research examining physiological responses to bereavement-related emotions.

Implementing Psychological First Aid for Healthcare Workers During the COVID-19 Pandemic: A Feasibility Study of the ICARE Model.

Maintaining the resilience of healthcare workers (HCWs) during the protracted COVID-19 pandemic is critical as chronic stress is associated with burnout, inability to provide high-quality care, and decreased attentiveness to infection prevention protocols. Between May and July 2020, we implemented the ICARE model of psychological first aid (PFA) in a novel online (i.e., telehealth) format to address the psychological support needs of HCWs during the COVID-19 pandemic. We found that HCWs needed psychological support related to obtaining clear information about pandemic policies and guidelines, navigating new rules and responsibilities, and processing overwhelming and conflicting emotions. The HCWs in our program repeatedly expressed appreciation for the support we provided. Future directions include establishing online discussion forums, increasing opportunities for individual support, and training HCWs to provide peer support using PFA. This program has far-reaching potential benefit to HCWs and to society at large in the context of a pandemic.

Dwelling in prolonged grief: Resting state functional connectivity during oxytocin and placebo administration.

Clinical theories of adaptation in bereavement highlight a need for flexible shifting between mental states. However, prolonged motivational salience of the deceased partner may be a complicating factor, particularly when coupled with perseverative thinking about the loss. We investigated how prolonged grief symptoms might relate to resting state functional brain network connectivity in a sample of older adults (n = 38) who experienced the death of a partner 6-36 months prior, and whether intranasal oxytocin (as a neuropeptide involved in pair-bonding) had differential effects in participants with higher prolonged grief symptoms. Higher scores on the Inventory of Complicated Grief (ICG) were associated with lower anticorrelation (i.e., higher functional connectivity) between the defaultretrosplenial - cingulo-operculardACC network pair. Intranasal oxytocin increased functional connectivity in the same defaultretrosplenial - cingulo-operculardACC circuit but ICG scores did not moderate effects of oxytocin, contrary to our prediction. Higher ICG scores were associated with longer dwell time in a dynamic functional connectivity state featuring positive correlations among default, frontoparietal, and cingulo-opercular networks, across both placebo and oxytocin sessions. Dwell time was not significantly affected by oxytocin, and higher prolonged grief symptoms were not associated with more variability in dynamic functional connectivity states over the scan. Results offer preliminary evidence that prolonged grief symptoms in older adults are associated with patterns of static and time-varying functional network connectivity and may specifically involve a default network-salience-related circuit that is sensitive to oxytocin.

From Grief to Grievance: Combined Axes of Personal and Collective Grief Among Black Americans.

In the current article, we argue that the current conceptualization of grief as "the acute pain that accompanies the loss of a loved one" is too narrow in scope. Specifically, our current conceptualization of grief fails to account for the various ways in which grief is manifested amongst Black Americans. Throughout the article, we explore how the history of the racialization of Black people in America has resulted in a unique experience of loss, grief, and bereavement which previous research has largely failed to elucidate. Additionally, we explore how grief catalyzes political and social action. The article also proposes a novel theoretical conceptualization of personal and collective grief to deepen our conceptualization of grief amongst Black Americans. Finally, we posit that we must also consider how to further research on this collective grief to increase our understanding of it and to account for similar phenomena that may exist in communities who've had similar experiences (e.g., Indigenous peoples in the Americas and Dalits in India).

Grieving as a form of learning: Insights from neuroscience applied to grief and loss.

Recent grief research suggests that the influential cognitive stress theory should be updated with evidence from cognitive neuroscience. Combining human and animal neuroscience with attachment theory, we propose that semantic knowledge of the everlasting nature of the attachment figure and episodic, autobiographical memories of the death are in conflict, perhaps explaining the duration of grieving and generating predictions about complications in prolonged grief disorder (PGD). Our gone-but-also-everlasting model emphasizes that grieving may be a form of learning, requiring time and experiential feedback. Difficulties before loss, such as spousal dependency or pre-existing hippocampal volume, can prolong learning and predict PGD. Complications such as avoidance, rumination, and stress-induced hippocampal atrophy may also develop after loss and create functional or structural mechanisms predicting PGD.

The think aloud paradigm reveals differences in the content, dynamics and conceptual scope of resting state thought in trait brooding.

Although central to well-being, functional and dysfunctional thoughts arise and unfold over time in ways that remain poorly understood. To shed light on these mechanisms, we adapted a "think aloud" paradigm to quantify the content and dynamics of individuals' thoughts at rest. Across two studies, external raters hand coded the content of each thought and computed dynamic metrics spanning duration, transition probabilities between affective states, and conceptual similarity over time. Study 1 highlighted the paradigm's high ecological validity and revealed a narrowing of conceptual scope following more negative content. Study 2 replicated Study 1's findings and examined individual difference predictors of trait brooding, a maladaptive form of rumination. Across individuals, increased trait brooding was linked to thoughts rated as more negative, past-oriented and self-focused. Longer negative and shorter positive thoughts were also apparent as brooding increased, as well as a tendency to shift away from positive conceptual states, and a stronger narrowing of conceptual scope following negative thoughts. Importantly, content and dynamics explained independent variance, accounting for a third of the variance in brooding. These results uncover a real-time cognitive signature of rumination and highlight the predictive and ecological validity of the think aloud paradigm applied to resting state cognition.

A controlled trial of two mind-body interventions for grief in widows and widowers.

Objective: Following bereavement, yearning and grief rumination are repetitive cognitive processes that can lead to disordered grief. Mindfulness training (MT) has been shown to reduce maladaptive repetitive thought. The current quasi-randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of MT for bereavement-related grief. Method: Ninety-five widow(er)s (Mage = 67.5, 79% women, 98% White) between 6 months to 4 years post-loss were assigned to a 6-week MT intervention or a progressive muscle relaxation (PMR) intervention, or a wait-list condition. Outcome measures were grief severity (Revised Inventory of Complicated Grief), yearning (Yearning in Situations of Loss), rumination (Utrecht Grief Rumination Scale), and decentering (Experiences Questionnaire-Decentering) assessed at baseline, Weeks 2 and 4 of intervention, post-intervention, and 1-month post-intervention. Growth curve analysis examined group differences in rates of improvement in outcomes through follow-up and associations with improvement in grief severity. Results: The MT and PMR groups showed significant rates of decline in grief severity and yearning, though only the PMR group showed a greater rate of decline in grief severity than wait-list. All groups showed significant rates of decline in grief rumination. The PMR and wait-list groups showed significant rates of increase in decentering compared to the MT group. Conclusions: Results support the feasibility and acceptability of MT and PMR for widow(er)s as well as the preliminary efficacy of PMR for improving grief severity in widow(er)s compared to a wait-list control condition. With replication, PMR could be a standalone intervention for non-disordered grief or a component of treatment for disordered grief. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The longitudinal association of actigraphy-estimated sleep with grief in middle-aged and elderly persons.

Most people experience grief after a loss, about 10% develop complicated grief, often accompanied by sleep complaints. Yet, the role of objectively estimated poor sleep remains unclear. Therefore, we assessed the cross-sectional and longitudinal association of actigraphy-estimated sleep with grief. We included 1,776 participants (mean age: 61.8 ± 8.9 years, 55% women) of a prospective population-based cohort. Of 1,471 participants (83%) repeated measures of grief were available (median follow-up 6 years, inter quartile range 5.6-6.3). At baseline, sleep was objectively estimated using actigraphy (mean duration 6.0 ± 0.8days). At baseline and follow-up, participants were asked about significant losses and completed the Dutch Inventory of Complicated Grief (17 items, cut-off ≥22). At baseline 1,521 (86%) participants experienced no grief, 44 (2%) acute grief (<6 months, any grief score), 158 (9%) non-complicated grief (≥6 months, grief score<22), and 53 (3%) complicated grief (≥6 months, grief score≥22). In those indicating any grief (n = 255), low sleep efficiency (B = -0.16, 95%CI = -0.30;-0.02), long sleep onset latency (B = 0.07, 95%CI = 0.01; 0.14), and long wake after sleep onset (B = 0.06, 95%CI = 0.01; 0.10) were cross-sectionally associated with more grief symptoms. Over time, those with a short total sleep time (OR = 0.59, 95%CI = 0.39; 0.91), low sleep efficiency (OR = 0.95, 95%CI = 0.91; 0.99), long sleep onset latency (OR = 1.02, 95%CI = 1.00; 1.04), and long wake after sleep onset (OR = 1.02, 95%CI = 1.00; 1.03) at baseline more often experienced complicated grief than non-complicated grief at follow-up. This study suggests that objectively estimated poor sleep is associated with grief over time. Poor sleep might not only accompany grief, but also be a risk factor for developing complicated grief after a loss.

Wish you were here: The Dutch, German, and English Yearning in Situations of Loss Short Form.

OBJECTIVE(S): Yearning, a hallmark of grief disorders, relates to rumination and potentially to cognitive avoidance. We developed an 8-item short form of the only existing validated yearning measure, the Yearning in Situations of Loss Scale (YSL), to improve its validity and administration ease. METHOD: Cross-sectional surveys were conducted among bereaved Dutch (N = 313) and German (N = 235) community samples and an American treatment-seeking sample (N = 95). All samples completed the YSL, and community samples additionally measures of rumination, loss-related avoidance, complicated grief (CG), and depression. RESULTS: A one-factor model provided a good fit to the YSL Short Form (YSL-SF) in the community samples. A two-factor structure (cognitive and emotional yearning)best fitted the YSL-SF in the treatment-seeking sample. YSL-SF scores correlated positively with rumination, loss-related avoidance, and with CG symptoms whilst controlling for rumination and loss-related avoidance. CONCLUSION: The YSL-SF appears an easy-to-administer and valid measure of yearning after bereavement.

Recruitment and retention in clinical and experimental bereavement research: Lessons learned from creating a research registry.

A small body of research investigates recruitment and retention of bereaved people in experimental and intervention research. The present study compares the effectiveness of different recruitment strategies implemented by a grief laboratory at a large state university in order to optimize recruitment efforts. The most effective method is letters sent to bereaved community members identified through online newspaper obituaries. Despite a small overall response rate, the large population from which to sample provides continuous accrual every month. Other methods include electronic/print media, community institution referrals, word of mouth and community outreach. Best practices for recruitment and retention are recommended.

The role of personal and communal religiosity in the context of bereavement.

Religion and spirituality often become relevant after the death of a loved one. In light of the multidimensionality of religion and spirituality, we investigate the role of communal religiosity in predicting associations between personal religiosity and bereavement outcomes. A mixed-methods analysis of interviews and questionnaires from 33 bereaved adults was conducted. Interview mentions of personal and communal religiosity, and their associations with self-reported religious coping and grief symptoms, were assessed. Personal (ß = 0.55, p < .01) and communal religiosity (ß = 0.50, p < .01) predicted positive religious coping, as well as negative religious coping and grief severity (ß = 0.53, p < .01). In addition, personal religiosity predicted more negative religious coping for participants who expressed low communal religiosity, ß = 1.58, SE = .15, t(28) = 4.08, p < .001. After loss, personal religiosity by itself is not necessarily protective. The presence of personal and communal religiosity contributes to positive religious coping, and reduced negative religious coping. However, the absence of communal religiosity indicates vulnerability.

Gender differences in grief narrative construction: a myth or reality?

Background: Narratives play a central role in the recovery process following death, and linguistic properties of grief narratives can serve as indicators of adjustment to loss. The present study examined whether bereaved men and women differ in how they discuss their loss, and how linguistic markers relate to psychological functioning. Positive associations were hypothesized between first-person singular pronoun use and psychological distress. Gender differences were expected for different emotion and social process words, and overall word use. Exploratory analyses were conducted to assess the relationship between linguistic markers and psychosocial outcomes for men and women separately. Method: 50 bereaved widow(er)s and parents (29 women, 21 men; M Age = 71.16 years, SD = 9.95) completed psychosocial self-report questionnaires and individual in-depth interviews. Grief narratives were analysed using Linguistic Inquiry and Word Count (LIWC), a software program that quantifies words into linguistic and psychological categories. Results: Contrary to our hypothesis, first-person pronoun use was not related to psychological distress. Although gender differences emerged in self-reported psychosocial outcomes, we failed to find the predicted gender differences in linguistic markers (emotion and social process words, overall word count). Exploratory analyses revealed additional associations between linguistic markers and psychosocial outcomes, and gender differences in these relationships. Notably, first-person pronoun use was related to heightened grief avoidance. Furthermore, various linguistic markers were associated with increased depression levels in females, but not males. In contrast, nonfluencies were positively associated with indicators of psychological distress in men only. Conclusion: In line with the gender similarities hypothesis, analyses suggest similarities between men and women's discussion of their grief experience. Associations between linguistic markers and psychological adjustment indicate that grief narratives contain meaningful indices of underlying health.

Antecedentes: Las narrativas juegan un rol central en el proceso de recuperación posterior al fallecimiento, y las propiedades lingüísticas de las narrativas del duelo pueden servir como indicadores de adaptación a la pérdida. El presente estudio examinó si es que hombres y mujeres en proceso de duelo difieren en como discuten su pérdida, y como los marcadores lingüísticos se relacionan con el funcionamiento psicológico. Se hipotetizó que existirían asociaciones positivas entre uso del pronombre singular en primera persona y distrés psicológico. Se esperaban diferencias de género para distintas palabras sobre emociones y palabras de proceso social, y uso de palabras en general. Se realizaron análisis exploratorios para evaluar la relación entre marcadores lingüísticos y resultados psicosociales para hombres y mujeres por separado.Método: 50 personas en proceso de duelo, tanto viudos como padres (29 mujeres, 21 hombres, M edad =71.16, Desviación Estándar = 9.95) completaron cuestionarios psicosociales de auto-reporte y entrevistas individuales en profundidad. Las narrativas del duelo fueron analizadas por Investigación Lingüística y Conteo de Palabras (LIWC por sus siglas en inglés) un programa de software que cuantifica palabras en categorías lingüísticas y psicológicas.Resultados: Al contrario de nuestra hipótesis, el uso del pronombre en primera persona no se relacionó con distrés psicológico. Aunque emergieron diferencias de género en los resultados psicosociales auto-reportados, no logramos encontrar las diferencias de género que fueron previstas en los marcadores lingüísticos (palabras sobre emociones y proceso social, conteo de palabras en general). Los análisis exploratorios revelaron asociaciones adicionales entre marcadores lingüísticos y resultados psicosociales, y diferencias de género entre estas relaciones. Cabe destacar que el uso de pronombres en primera persona estuvo relacionado con aumentada evitación del dolour por la pérdida. Además, varios marcadores lingüísticos se asociaron con aumento de niveles de depresión en mujeres, pero no en hombres. En contraste, las no fluencias tuvieron asociación positiva con indicadores de distrés psicológico solamente en los hombres.Conclusión: En línea con las hipótesis de las similitudes entre géneros, los análisis sugieren similitud de la discusión de la experiencia de duelo entre hombres y mujeres. Las asociaciones entre marcadores lingüísticos y adaptación psicológica indican que las narrativas sobre el duelo contienen índices significativos de salud subyacente.

Grief: A Brief History of Research on How Body, Mind, and Brain Adapt.

OBJECTIVE: Using an integrative view of psychology, neuroscience, immunology, and psychophysiology, the present review of literature curates the findings that have had an impact on the field of bereavement research and shaped its development. METHODS: Beginning with pivotal systematic descriptions of medical and psychological responses to the death of a loved one by Lindemann in the mid-1940s, this selective review integrates findings in bereavement research from studies that investigate medical outcomes after loss, their psychological predictors, and biopsychosocial mechanisms. RESULTS: Morbidity and mortality after the death of a loved one have long been a topic of research. Early researchers characterized somatic and psychological symptoms and studied immune cell changes in bereaved samples. More recent research has repeatedly demonstrated increased rates of morbidity and mortality in bereaved samples, as compared with married controls, in large epidemiological studies. Recent developments also include the development of criteria for prolonged grief disorder (also termed complicated grief). Newer methods, including neuroimaging, have observed that the greatest impact of the death of a loved one is in those who have the most severe psychological grief reactions. Research addressing the mechanisms tying bereavement to medical outcomes is relatively scarce, but differences in rumination, in inflammation, and in cortisol dysregulation between those who adapt well and those who do not have been offered with some evidence. CONCLUSIONS: Recommendations to propel the field forward include longitudinal studies to understand differences between acute reactions and later adaptation, comparing samples with grief disorders from those with more typical responses, and integrating responses in brain, mind, and body.

Prolonged Grief Disorder and the Cultural Crisis.

Prolonged grief disorder (PGD) is included as a new mental health disorder in the 11th edition of the International Classification of Diseases (ICD-11). Understandably, this has boosted research efforts to investigate this newcomer to psychopathology. However, the use of different diagnostic algorithms has resulted in substantially different prevalence rates both within and across cultural groups. Furthermore, global applicability of the new criteria outside of the Global North has not been yet been established. This perspective presents key findings from Asian research groups and discusses the roadblocks to unified PGD research, including the heterogeneric use of diagnostic algorithms and the lack of cultural compatibility of ICD-11 items. The authors discuss the key issues and address implications for practice.

Yearning predicts subgenual anterior cingulate activity in bereaved individuals.

Complicated grief, or persistent complex bereavement disorder, is a condition that affects approximately 10% of bereaved individuals and is marked by intense longing and yearning for the deceased. Little is known about the neurocognitive mechanisms contributing to this syndrome, but previous research suggests that reward pathways in the brain may play a role. Twenty-five older adults were categorized based on grief severity into one of three groups: complicated grief (CG), non-complicated grief (NCG) and non-bereaved married controls (NB). Neural activation was examined using fMRI while participants viewed a countdown on the screen (anticipation) followed by a photo of their (living or deceased) spouse. There was no significantly differential activation between the three groups for the spouse v. stranger photo contrast, nor for anticipation period v. spouse photo. Post-hoc analyses were conducted using self-reported yearning scores as a regressor across all bereaved participants, which revealed that greater symptoms of yearning predicted greater activation in the subgenual anterior cingulate cortex (sgACC). Given the small sample size, the results should be considered preliminary and in need of replication, but may suggest a more nuanced, transdiagnostic role of the sgACC. This region of the brain has been previously linked to depression and suggests that symptoms of yearning may present an opportune place to intervene to improve outcomes in CG.