فرآیندهای واسطه ای در داغدیدگی: نقش نشخوار فکری، تهدید تفسیرهای غم و اندوه، غم و اندوه و اجتناب آگاهانه

Limited research so far has examined coping processes that mediate between risk factors and bereavement outcome. Knowledge of these pathways is important, since it helps establish why some bereaved persons are more vulnerable than others and suggests possibilities for intervention. In this international longitudinal study, three potentially critical mediators, namely rumination, threatening grief interpretations and deliberate grief avoidance, were examined in relationship to previously established risk factors (e.g., expectedness of the death, attachment style) and four major outcome variables (grief, depressive symptoms, emotional loneliness and positive mood). Individuals who were recently bereaved (maximum 3 years) filled in questionnaires at three points in time. Results showed that rumination and – to a somewhat lesser extent – threatening grief interpretations played an important role in mediating the effects of various risk factors on outcomes. However, the contribution of these two mediators was dependent on the specific risk factor and outcome measure under consideration. For example, whereas the effect of neuroticism on grief was mediated by both processes (to the extent of 73%), the effect of neuroticism on positive mood was only mediated by rumination and to a smaller extent (23%). A few risk factors, such as current financial situation and spirituality, were not mediated by either coping strategy. Implications of these findings are discussed.

Bereavement is a highly stressful life-event that is associated with excess risk of mortality and with decrements in both physical and mental health (for a review, see Stroebe, Schut, & Stroebe, 2007). While most people are able to adjust to the death of a loved one without long-lasting difficulties, a significant minority of the bereaved do not adapt well and continue to experience difficulties (Bonanno & Mancini, 2008). Much research has focused on so-called “risk factors”, that is, situational and personal characteristics likely to be associated with increased vulnerability across the spectrum of bereavement outcome variables (Stroebe, Folkman, Hansson, & Schut, 2006). An important impetus for this line of work is that early identification of those at risk of suffering lasting health consequences makes it possible to intervene and possibly prevent negative outcomes. It is particularly critical to identify such at-risk persons, because there is no empirical evidence that provision of routine psychological intervention, simply on the grounds that a person has suffered a bereavement, is effective (Currier, Neimeyer, & Berman, 2008). Although the above line of research is clearly valuable, it is also limited in the sense that it fails to inform one about pathways through which these predictors reach their effects. How, for instance, do unexpected deaths become associated with complications in bereavement? Knowledge of intermediate mechanisms is essential, not just for theoretical but also for practical purposes. For example, knowledge of the pathways through which risk factors influence bereavement outcome should enable us to identify cognitive processes that may be amenable to change, and provide us with targets for intervention. This is imperative, because many risk factors themselves are either resistant to change (e.g., personality factors, such as neuroticism and attachment style) or cannot be changed at all (e.g., risk factors having to do with the deceased and the bereavement situation). In a previous study a number of situational and personal characteristics that are associated with increased vulnerability after bereavement were identified (van der Houwen, Stroebe, et al., 2010; see Table 1 for an overview of these factors). All of these risk factors exerted their influence through main effects. There were no interactions with time of measurement. Thus, even though there was significant improvement in grief, depressive symptoms, emotional loneliness and positive mood during the course of this study, these risk factors appeared to neither accelerate nor slow down this process. Table 1. Overview of risk factors. Grief Depressive symptomsa Emotional loneliness Positive mood B SE B SE B SE B SE Gender (0 = male, 1 = female) 5.878∗∗∗ 1.694 −3.656∗ 1.786 Attachment anxiety 0.034∗∗∗ 0.008 Attachment avoidance 0.064∗∗∗ 0.017 0.115∗∗∗ 0.026 0.033∗∗∗ 0.008 −0.124∗∗∗ Neuroticism 0.157∗ 0.072 0.329∗∗ 0.103 0.266∗∗∗ 0.075 Spirituality 1.033∗ 0.438 Kinship (0 = partner) Parent −1.219∗ 0.566 Child −1.588∗∗∗ 0.464 Sibling −0.166 0.821 (Un)expectedness 1.214∗∗∗ 0.324 1.133∗ 0.464 Financial situation deterioration 1.845† 0.947 1.077∗ 0.431 Adequacy of financial situation −3.316∗ 1.416 Social support 1.134∗∗ 0.351 1.785∗∗∗ 0.535 −1.230∗∗ 0.397 †p < .10; p < .05; ∗∗p < .01; ∗∗∗p < .001. a We also found that taking medications for anxiety, mood or sleep problems was related to depressive symptoms. This factor was not included in the analyses because we felt these variables were directly related (without mediating processes). Table options In the current study we build on this previous research to examine mechanisms that mediate the impact of these risk factors, focusing on cognitive and behavioural coping processes (while recognizing that there are other mechanisms that influence bereavement outcome). Although a considerable amount of research has been devoted to these processes and how they influence bereavement outcome, to our knowledge, few studies have simultaneously examined risk factors, outcomes and the coping processes that might mediate between them. Some of these studies have focused on specific types of bereavement, whereas others have examined more general risk factors. We review these two types of investigation in turn next. Field et al investigated mediating factors in adjustment among a sample of conjugally bereaved people (Field et al., 1999 and Field and Sundin, 2001). They showed that the effects of anxious attachment (to the deceased spouse) and previous relationship conflict (with the deceased spouse) were mediated by the appraised inability to cope and by blame-related appraisals respectively. Wolchik et al examined the mediational properties of three self-system beliefs (fear of abandonment, coping efficacy, and self-esteem) between post-bereavement stressors (e.g., changes in living situations) and caregiver–child relationship quality, on the one hand, and mental health problems (e.g., internalizing and externalizing problems) on the other within a sample of parentally bereaved children (Wolchik et al., 2008 and Wolchik et al., 2006). They found – among other things – that fear of abandonment mediated the relations between stressors and both internalizing problems and externalizing problems when examined longitudinally. Turning now to the investigations that have focused on more general risk factors: Meuser and Marwit (1999) and Robinson and Marwit (2006) investigated whether different forms of coping mediated the relationship between personality and bereavement outcome, and concluded that the effect of neuroticism on grief was partly mediated by emotion-oriented coping. Currier, Holland, and Neimeyer (2006) examined sense-making (i.e., the capacity to construct an understanding of the loss experience) as a possible mediator between violent death and complicated grief symptomatology. They reported that sense-making emerged as an explanatory mechanism for the association between violent loss and complications in grieving. Nolen-Hoeksema, Parker, and Larson (1994) hypothesized and confirmed that the effect of four different risk factors (female gender, additional stress, poor social support and initially severe depressive reactions) on depressive reactions was mediated by rumination. In another study the same researchers demonstrated that sense-making and benefit-finding mediated the effects of dispositional optimism-pessimism, religious-spiritual beliefs, and the age at death of the deceased on distress (a composite measure of depressive symptoms, PTSD symptoms, and positive affect, reverse coded) (Davis, Nolen-Hoeksema, & Larson, 1998). The above research clearly identifies a number of central processes relating to bereavement outcomes. However, knowledge about mediational coping processes remains limited: (1) A number of the risk factors studied are specific to certain types of bereavement, which limits the applicability of the information acquired to these particular kinds of bereavement; (2) Additional, potentially important mediators have not yet been investigated. How can one identify such mediators? As mentioned earlier, although few studies have simultaneously examined risk factors, outcomes and the coping processes that might mediate between them, further research has indeed investigated a number of coping processes that might account for differences in bereavement outcome. Examples of processes that have received attention over the years are emotional expression (e.g. Stroebe, Stroebe, Schut, Zech, & van den Bout, 2002), cognitive appraisals (e.g. Boelen, van den Bout, & van den Hout, 2006), continuing bonds (e.g. Boelen, Stroebe, Schut, & Zijerveld, 2006), meaning-making (e.g. Davis et al., 1998), rumination (e.g. Nolen-Hoeksema, 2001), and deliberate grief avoidance (e.g. Shear et al., 2007). While all of these processes may be important, in this study we focus on coping processes that have consistently been associated with poor adjustment, either in cross-sectional or longitudinal studies: rumination, threatening grief interpretations (i.e., negative and fearful interpretations of grief reactions that are not necessarily indicative of disturbance) and deliberate grief avoidance. Moreover, some theorists have claimed that negative cognitions and avoidance (among which rumination can be counted, see e.g., Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008) play a central role in the development and maintenance of complicated grief ( Boelen et al., 2006 and Shear et al., 2007). Thus, it seems particularly important to investigate the mediating role of these three processes in the relationship between risk factors and outcome variables. In summary then, in this study we examined the mediating properties of rumination, threatening grief interpretations and deliberate grief avoidance between general risk factors (that were identified as important in an earlier study) and outcome in terms of grief, depressive symptoms, emotional loneliness and positive mood.