Searching for meaning in loss: are clinical assumptions correct.

Three assumptions guiding research and clinical intervention strategies for people coping with sudden, traumatic loss are that (a) people confronting such losses inevitably search for meaning, (b) over time most are able to find meaning and put the issue aside, and (c) finding meaning is critical for adjustment or healing. We review existing empirical research that addresses these assumptions and present evidence from a study of 124 parents coping with the death of their infant and a study of 93 adults coping with the loss of their spouse or child to a motor vehicle accident. Results of these studies indicate that (a) a significant subset of individuals do not search for meaning and yet appear relatively well-adjusted to their loss; (b) less than half of the respondents in each of these samples report finding any meaning in their loss, even more than a year after the event; and (c) those who find meaning, although better adjusted than those who search but are unable to find meaning, do not put the issue of meaning aside and move on. Rather, they continue to pursue the issue of meaning as fervently as those who search but do not find meaning. Implications for both research and clinical intervention are discussed.

The impact of widowhood on depression: findings from a prospective survey.

BACKGROUND: We investigated the impact of widowhood on depression and how resources and contextual factors that define the meaning of loss modified this effect. METHOD: In a prospective, nationally representative sample of women in the US aged 54 or older we compared 64 women who were widowed in the 3 years between data collection waves with 431 women who were stably married over the time interval. RESULTS: Those who became widowed reported more depression than controls for 2 years following the loss. However, this effect was confined to respondents whose husbands were not ill at baseline. Widowed women whose husbands were ill at baseline already had elevated depression in the baseline interview and did not become significantly more depressed after the death. Consistent with this result, women who were not depressed pre-bereavement were most vulnerable to depression following the loss of an ill spouse during the first year of widowhood. CONCLUSIONS: Results suggest that spouses' illness may forewarn wives of their impending loss and these women may begin to grieve before his death. Those forewarned women who are not depressed pre-bereavement may experience the most post-bereavement depression. Findings are discussed in light of previous, more methodologically limited studies.

Consensus criteria for traumatic grief. A preliminary empirical test.

BACKGROUND: Studies suggest that symptoms of traumatic grief constitute a distinct syndrome worthy of diagnosis. AIMS: A consensus conference aimed to develop and test a criteria set for traumatic grief. METHOD: The expert panel proposed consensus criteria for traumatic grief. Receiver operator characteristic (ROC) analyses tested the performance of the proposed criteria on 306 widowed respondents at seven months post loss. RESULTS: ROC analyses indicated that three of four separation distress symptoms (e.g. yearning, searching, loneliness) had to be endorsed as at least 'sometimes true' and four of the final eight traumatic distress symptoms (e.g. numbness, disbelief, distrust, anger, sense of futility about the future) had to be endorsed as at least 'mostly true' to yield a sensitivity of 0.93 and a specificity of 0.93 for a diagnosis of traumatic grief. CONCLUSIONS: Preliminary analyses suggest the consensus criteria for traumatic grief have satisfactory operating characteristics, and point to directions for further refinement of the criteria set.

Emotional expression and physical health: revising traumatic memories or fostering self-regulation?

Health benefits derived from personal trauma disclosure are well established. This study examined whether disclosing emotions generated by imaginative immersion in a novel traumatic event would similarly enhance health and adjustment. College women, preselected for trauma presence, were randomly assigned to write about real traumas, imaginary traumas, or trivial events. Yoked real-trauma and imaginary-trauma participants wrote about real-trauma participants' experiences. Imaginary-trauma participants were significantly less depressed than real-trauma participants at immediate posttest, but they were similarly angry, fearful, and happy. Compared with control group participants, both trauma groups made significantly fewer illness visits at 1-month follow-up; however, real-trauma participants reported more fatigue and avoidance than did the other groups. Imaginary-trauma group effects could reflect catharsis, emotional regulation, or construction of resilient possible selves.

Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers.

The study examined how social constraints on discussion of a traumatic experience can interfere with cognitive processing of and recovery from loss. Bereaved mothers were interviewed at 3 weeks (T1), 3 months (T2), and 18 months (T3) after their infants' death. Intrusive thoughts at T1, conceptualized as a marker of cognitive processing, were negatively associated with talking about infant's death at T2 and T3 among socially constrained mothers. The reverse associations were found among unconstrained mothers. Controlling for initial level of distress, there was a positive relation between T1 intrusive thoughts and depressive symptoms over time among socially constrained mothers. However, higher levels of T1 intrusive thoughts were associated with a decrease in T3 depressive symptoms among mothers with unconstrained social relationships.

The five-factor model of personality as a framework for personality-health research.

The NEO Five Factor Personality Inventory (NEO-FFI; Costa & McCrae, 1989) and representative personality scales drawn from health psychology were administered to 2 samples of male military recruits (Ns = 296 and 502). Factor analysis of health-related personality scales revealed 3 conceptually meaningful domains. Examination of these domains and their constituent scales, with reference to the 5-factor model of personality, permits 3 general conclusions. First, most health-relevant dimensions and scales appear to be complex mixtures of broad personality domains. Second, variation in many health-related personality instruments is explained to a significant degree by the 5-factor model. Third, 2 of the 5 personality domains (i.e., conscientiousness and openness) appear to be substantially neglected in health psychology research.

Religion's role in adjustment to a negative life event: coping with the loss of a child.

Parents (N = 124) who had lost an infant to sudden infant death syndrome were interviewed 3 weeks and 18 months postloss. Two components of religion (religious participation and religious importance) were assessed, and their relations with 3 coping-process variables (perceived social support, cognitive processing of the loss, and finding meaning in the death) were examined. Greater religious participation was related to increased perception of social support and greater meaning found in the loss. Importance of religion was positively related to cognitive processing and finding meaning in the death. Furthermore, through these coping-process variables, religious participation and importance were indirectly related to greater well-being and less distress among parents 18 months after their infants' deaths. Results suggest that further study of the social and cognitive aspects of religion would be profitable.

Social relationships of men at risk for AIDS.

Survey data collected in 1984-85 from a community sample of 637 gay and bisexual men were used to determine the features of social relationships that were most conductive to changes in both psychological health and AIDS-related sexual risk behavior. Multiple regression analyses showed that both the perceived availability of social support and the absence of conflicts in the social network were related to improve psychological health. At the same time, the subjective experience of integration into social networks was associated with increased psychological distress, and validation (the experience of being accepted by others) was related to a higher level of risk activity. These findings are discussed in terms of the social relationships among community members that share a common stressor--in this case the shared problem of being at risk for AIDS.

A longitudinal study of psychological distress in a cohort of gay men. Effects of social support and coping strategies.

This study presents analyses on questionnaire data collected from a panel of 520 gay men at risk for acquired immune deficiency syndrome, enrolled in the Coping and Change Study (1985-1987). The data were assessed to determine the association of social support and coping styles with subsequent depression and global distress and to investigate whether these predictors of mental health are stable or transient over time. Three different measures of the subjective, qualitative nature of social support were significantly associated with subsequent mental health. Those who reported a subjective sense of isolation experienced significantly more adverse mental health 6 months later at all three measurement periods. Scattered effects were found for perceived social conflict and perceived social support from others. These results indicate that certain types of social support appear to influence mental health in this cohort and, furthermore, that some associations are transient and others more stable over time.

Widowhood and depression: explaining long-term gender differences in vulnerability.

Results from a 1986 national survey (N = 3,614) show that having ever been widowed is associated with current levels of depression and that this association is greater for men than women. Some of this apparent gender difference occurs because men have been widowed for a shorter average period of time than women and the effects of widowhood appear to lessen over time. Widowhood also is associated with different types and amounts of life strain for men and women. The results suggest that the primary mechanism linking widowhood to depression among women is financial strain. Among men, the more critical mechanisms seem to be strains associated with household management. When specific strains occur, they appear to have different effects on respondents who have ever been widowed and those who have not. Taken together, these results suggest that what appears on the surface to be a gender difference in vulnerability to the same life event turns out upon closer examination to occur because widowhood does not affect men and women in the same way.

Sharing of home responsibilities between professionally employed women and their husbands.

A sample of 139 married couples with young children and with relatively equal status careers (wives were university professors or businesswomen) were interviewed about work and home life. Considerable, traditional inequity in the distribution of child-care tasks and chore responsibility was noted, but women were generally satisfied with their husbands' home involvement. In the academic sample, the longer hours each spouse worked, the more child care the other performed; in the business sample, child-care involvement was largely determined by the husband's work hours, income, and education. Overall, women were more self-critical than were men about their performance in home roles, and women's role performance was rated more highly by husbands than by themselves. Women professionals' continued use of traditional sex role standards and the importance of attending to both partners' perspectives in studies of married life are discussed.

Reconsidering the attribution-adjustment relation following a major negative event: coping with the loss of a child.

Field studies have not yet conclusively established how attributions affect adjustment to unanticipated traumatic events. This may be due, in part, to the adoption of several untested assumptions in most prior research. It has usually been assumed that attributional issues are important to people who experience a traumatic event, that such concern is adaptive, and that specific attributions (e.g., self-blame) influence subsequent adjustment. These assumptions were tested with longitudinal data collected over 18 months from 124 parents whose child died of Sudden Infant Death Syndrome. By 3 weeks postloss, 45% of parents were not concerned with attributional issues. These parents were less distressed and less likely to blame themselves or others for the death. Longitudinal analyses did not support the assumption that attributions influence subsequent adjustment. Rather, attributions to onself or others appear to be symptomatic of distress.

Psychological functioning in a cohort of gay men at risk for AIDS. A three-year descriptive study.

This study describes the mental health of a large cohort of gay men participating in the Chicago Multicenter AIDS Cohort Study/Coping and Change Study. Six biannual questionnaires were self-administered between 1984 and 1988. General mental health was determined by the Hopkins Symptom Checklist (HSCL). An abbreviated version of the Center for Epidemiologic Study Depression Scale (CESD-5) and an adapted Diagnostic Interview Schedule (DIS) question also measured depression. Suicidal ideation was assessed by one question in the HSCL. AIDS-specific distress was determined by three subscales specifically developed for this study. While mean HSCL and CESD-5 scores were stable during the observational period, AIDS-specific distress increased over time. The HSCL scores for the cohort were somewhat elevated above general population norms but considerably below psychiatric outpatient norms. Fewer than 12% of the men reported elevated HSCL or CESD-5 scores three or more times. A self-reported episode of depression of two weeks or more, measured by the DIS screening question, was experienced by 40.1% of the sample. Suicidal ideation was reported on three or more visits by 18.8% of the men. The younger members of this cohort exhibit greater general and AIDS-specific distress. Income was inversely associated with general distress. HIV-seropositive participants had generally higher AIDS-specific distress scores than those who were seronegative, but their scores were equivalent on the HSCL and CESD-5.

Models of helping and coping in cancer care.

This paper provides a theoretical analysis of four models of helping and coping as they relate to cancer care. The four conceptual models focus on the issue of whether or not patients should be viewed as responsible for the cause or the treatment of their cancer. The moral model, characterized by the holistic health movement, holds patients responsible for both causing and resolving health problems. The compensatory model, exemplified by cancer education programs, attributes low responsibility to patients for causing health problems but high responsibility for resolving them. The medical model views patients as neither responsible for causing nor for resolving health problems. The enlightenment model, typified by the healing movement, holds people responsible for causing their health problems, but not for resolving them. An attempt is made to examine existing programs in cancer care in light of these models. The present analysis addresses the following questions. Why is each of these models appealing? Why are they sometimes embraced by patients or health care providers? What are the benefits and disadvantages of using each of these models with cancer patients? What happens when the health care provider and patient hold different models regarding the patient's responsibility or participation in the cause of the disease or its treatment? Further research is needed to determine the conditions under which a particular model results in better health outcomes for patients, and to assess how factors such as extent of disease or type of cancer influence the patient's choice of a model.

The myths of coping with loss.

Drawing from theory and clinical lore, we consider how individuals are assumed to cope following irrevocable loss. Several assumptions are reviewed reflecting beliefs concerning the grieving process. Specifically, we examine the expectation that depression is inevitable following loss; that distress is necessary, and failure to experience it is indicative of pathology; that it is necessary to "work through" or process a loss; and that recovery and resolution are to be expected following loss. Although limited research has examined these assumptions systematically, available empirical work fails to support and in some cases contradicts them. Implications of our analysis for theoretical development and research are explored. Finally, we maintain that mistaken assumptions held about the process of coping with loss fail to acknowledge the variability that exists in response to loss, and may lead others to respond to those who have endured loss in ways that are unhelpful.

Effects of HIV infection, perceived health and clinical status on a cohort at risk for AIDS.

Data from a general population sample of 621 healthy homosexual men are used to evaluate the social and emotional effects of HIV antibody status, clinical signs detected by medical examination, and subjectively perceived symptoms. Participants are unaware of their serologic status at the time of data collection, thus allowing the effects of the virus to be separated from reactions to the knowledge of serologic status. The data show that seropositivity for HIV is not associated with elevated levels of social or emotional impairment. Clinical signs lead to impairment in baseline data, but these effects do not persist at a second wave. This weakening suggests that the effects are mediated by psychological pathways rather than biologic ones. This suspicion is confirmed in further analyses, which show that the effects of clinical signs are mediated by subjectively perceived symptoms. These results show that neither social nor emotional impairment is likely to be a prodromal sign of HIV infection in otherwise healthy homosexual men. The substantial levels of distress found among these men is more directly influenced by psychological determinants than biologic ones. This suggests that physicians should be aware of the psychological toll imposed on gay men who develop health problems in the current atmosphere of uncertainty regarding risk of AIDS.

Long-term effects of losing a spouse or child in a motor vehicle crash.

In this article we examine the long-term effects of the sudden, unexpected loss of a spouse or child. In the spouse study, interviews were conducted with 39 individuals who had lost a spouse in a motor vehicle crash 4 to 7 years ago and with 39 matched controls. In the parent study, interviews were conducted with 41 parents who had lost a child in a crash and with 41 matched controls. Control respondents were matched to bereaved respondents case-by-case on the basis of sex, age, income, education, and number and ages of children. Significant differences between bereaved spouses and controls were revealed on several indicators of general functioning, including depression and other psychiatric symptoms, social functioning, psychological well-being, reactivity to good events, and future worries and concerns. For the most part, these differences persisted when variables such as present family income and present marital status were statistically controlled. Comparisons between bereaved and control parents also revealed significant differences on some measures of general functioning (especially depression), but these were not as pervasive as the differences obtained in the spouse study. Responses to questions about current thoughts and feelings suggest that the deceased continued to occupy the thoughts and conversations of bereaved spouses and parents. Moreover, a large percentage of respondents (from 30% to 85%, depending on the question), continued to ruminate about the accident or what might have been done to prevent it, and they appeared to be unable to accept, resolve, or find any meaning in the loss. Taken together, the data provide little support for traditional notions of recovery from the sudden, unexpected loss of a spouse or child.

Social factors in psychopathology: stress, social support, and coping processes.

Our review has focused centrally on the etiologic significance of social factors in the development of psychopathology. Our implicit assumption has been that social factors in general, and stressors in particular, may play a causal role in the development of psychopathology. Yet the evidence is clear that the vast majority of people who are exposed to stressful life events or to chronic stress situations do not develop significant psychiatric impairments. For this reason, research interest over the past decade has shifted to factors like social support and coping strategies that may ameliorate the impact of stress. We have examined some of the important empirical results from recent studies of stress, support, and coping, and we have discussed ways in which these new understandings have informed long-standing attempts to explain group differences in emotional functioning. In each section of the review we have attempted not only to summarize existing results but also to provide some evaluation of the literature and suggestions for future research. It is important to recognize that the contributors to the work reviewed here do not all share a common research agenda. Some of them are primarily committed to unraveling the psychosocial determinants of a particular clinical disorder. Others are mainly concerned with the effects of a particular stressor. Still others are interested in the processes that link stress to health across a broad array of stress situations and health outcomes. In the face of these diverse interests, it is little wonder that our understanding of social factors in psychopathology is uneven. There is good reason to believe, however that these diverse strands of research are beginning to converge on a common conception of the stress process and on a common research design. The conception at present is only in rough form, but its outlines are nonetheless capable of description. At its center is the notion that stress exposure sets off a process of adaptation. It recognizes that this process unfolds over time, and it acknowledges that this process is modified by structural factors as well as by personal dispositions and vulnerabilities. There is growing recognition that the analysis of this process requires longitudinal methods. Also, it is becoming increasingly clear that experimental interventions are required to unravel the parts of this process that link stress and health. It is too early to know if this nascent convergence will lead to an integrative theory of adaptation, yet it is almost certain to promote methodological and conceptual rigor and facilitate replication and cumulation of findings.(ABSTRACT TRUNCATED AT 400 WORDS)