نشخوار فکری و اجتناب ضمنی بدنبال داغدیدگی: رویکرد بررسی کار اجتنابی

Background and objectives Rumination, a risk factor in adjustment to bereavement, has often been considered a confrontation process. However, building on research on worry in generalized anxiety disorder (GAD) and rumination in post-traumatic stress disorder (PTSD), researchers recently developed the Rumination as Avoidance Hypothesis (RAH), which states that rumination after bereavement serves to avoid the reality of the loss. In the present study, RAH was tested by investigating if rumination is associated with implicit loss avoidance. Methods An Approach Avoidance Task (AAT) was used to assess automatic behavior tendencies. Using a joystick, 71 persons who recently lost a first-degree relative (90.1% women), pulled stimuli toward themselves or pushed them away from themselves. Stimuli represented the loss (picture deceased + loss word), were loss-related but ambiguous (picture deceased + neutral word; picture stranger + loss word), or were non-loss-related (picture stranger + neutral word; puzzle picture + X's). Results Participants who ruminated more were relatively faster in pushing loss stimuli away from themselves and slower in pulling loss stimuli towards themselves, implying more rumination was associated with stronger implicit loss avoidance. Effects were maintained after controlling for depressive or post-traumatic stress symptom levels, but not when controlling for prolonged grief symptom levels. Limitations Conjugally bereaved women were overrepresented in the sample, which limits generalizability of results. The study was correlational, precluding causal inferences. Conclusions In line with RAH, rumination was positively associated with loss avoidance. This may indicate that the application of exposure-based techniques can reduce rumination and loss-related psychopathology.

Since the early days of bereavement research, behavioral theorists have considered approach and avoidance behavior to play a key role in adjustment to loss (e.g., Freud, 1917/1957, Lindemann, 1944, Ramsay, 1977 and Tait and Silver, 1989). For example, Freud (1917/1957) proposed that bereaved persons should counter avoidance, by engaging in ‘grief work’, a cognitive process of confronting the reality of the loss, in order to come to terms with the death of a loved one. Contemporary theorists similarly consider approach and avoidance to be central processes in understanding adjustment to bereavement (e.g., Boelen et al., 2006, Bonanno and Burton, 2013 and Stroebe and Schut, 2010). For example, in a cognitive-behavioral model of prolonged grief, Boelen et al. (2006) suggested that bereaved individuals may engage in avoidance of situations, places and objects, and in various cognitive avoidance strategies, such as suppression, to avoid painful aspects of the loss. Such avoidance is assumed to lead to development of prolonged grief, because it interferes with the integration of autobiographical memories about the loss with existing autobiographical memories (cf. a cognitive model of posttraumatic stress-disorder: Ehlers & Clark, 2000). In line with these theories, experiential avoidance (i.e., avoidance of internal experiences such as memories, thoughts and emotions), thought suppression and deliberate avoidance of reminders of the loss are concurrently and longitudinally associated with higher depressive, post-traumatic stress and prolonged grief symptoms (e.g., Boelen and van den Bout, 2010, Boelen and van den Hout, 2008, Bonanno et al., 2005, Eisma et al., 2013 and Morina, 2011). For instance, Bonanno et al. (2005) reported that stronger deliberate grief avoidance predicted poorer long-term adjustment in a sample of bereaved individuals. Moreover, cognitive-behavioral therapies including exposure techniques aimed at confronting bereaved individuals with emotionally overwhelming aspects of the loss, have been proven effective in reducing prolonged grief symptoms (e.g., Boelen et al., 2007, Shear et al., 2005 and Wagner et al., 2006). Despite the theoretical relevance and potential clinical applicability of knowledge about approach and avoidance processes in dealing with bereavement, not all typically-observed coping behavior in bereaved persons can straightforwardly be classified as falling on either side of this dimension. Most notably, rumination, thinking repetitively and recurrently about the causes and consequences of one's negative emotions (Nolen-Hoeksema & Morrow, 1991) and/or negative life-events (Michael, Halligan, Ehlers & Clark, 2007), has been conceptualized as both as an approach and an avoidance strategy. Since rumination after loss is related to increases in psychopathology and general distress (for a brief review: Eisma, Stroebe, et al., 2014), clarifying the function of rumination is critical for a better understanding of adjustment after bereavement. In the past, bereavement researchers have often more or less explicitly assumed rumination after loss to be similar to confrontation (e.g., Michael and Snyder, 2005, Nolen-Hoeksema, 2001, Nolen-Hoeksema and Larson, 1999 and Tait and Silver, 1989). For instance, Nolen-Hoeksema and colleagues characterized rumination as the “opposite to avoidance and denial/suppression” (Nolen-Hoeksema, 2001 and Nolen-Hoeksema and Larson, 1999, cf. Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008). According to her Response Style Theory, repetitive focus on causes and consequences of loss-related emotions fuels depression by: i) increasing availability of negative cognitions, ii) interfering with problem solving, iii) impeding instrumental behavior, and iv) driving away social support (Nolen-Hoeksema, 2001; cf. Nolen-Hoeksema et al., 2008). Similarly, self-regulation theorists consider rumination to be a discrepancy-focused thought process aimed at reducing discrepancies between a current reality a desired but yet unattained goal (e.g., Martin & Tesser, 1996). However, if a discrepancy cannot easily be resolved (e.g., when experiencing a major negative life-event), such recurrent cognitive focus on a negative topic can increase negative mood and depression. More recently, several researchers have proposed that rumination after bereavement is an avoidance process (Boelen et al., 2006 and Stroebe et al., 2007). Drawing upon research on worry in generalized anxiety disorder (e.g., Borkovec, Ray, & Stöber, 1998) and rumination after traumatic life-events (Ehlers & Clark, 2000), Stroebe et al. (2007) put forward the Rumination as Avoidance Hypothesis (RAH). This hypothesis states that chronic rumination about the loss-event and associated problems serves as an “excuse” not to face up to the most painful aspects of a loss-experience, such as the reality of the loss. Similarly, Boelen et al. (2006) argued that continuous rumination about one's own reactions and reasons why the loss occurred may be a way to “escape” from having to admit the fact of the loss and the emotions associated with it. In summary, whereas some researchers consider rumination to be a confrontation strategy, others have suggested that it may (also) be an avoidance process. Clarification of the function of rumination in bereavement is not only theoretically important, but may also have substantial clinical implications. Increasingly, cognitive-behavioral therapies (CBT) are being developed that target rumination and worry in order to reduce psychopathology (for a review: Querstret & Cropley, 2013). Potentially, CBT for prolonged grief may be improved by applying techniques that reduce rumination. Traditionally, it has been argued that rumination (being a confrontation process), can be disrupted by providing positive distraction, that is, by undertaking new meaningful activities (Nolen-Hoeksema et al., 2008 and Papa et al., 2013). However, should rumination be an avoidance process, the exposure-based therapy could (also) be a viable strategy to break the ruminative cycle (Boelen et al., 2006 and Eisma et al., 2013). Interestingly, some recent investigations provide support for an association between rumination and avoidance after bereavement. For example, in a cross-sectional survey study in female bereaved war survivors, Morina (2011) reported a moderate association between trait rumination and experiential avoidance. Recently, Eisma et al. (2013) extended these findings by demonstrating in a large bereaved sample that the prospective relationship between rumination and prolonged grief symptom change was mediated by experiential avoidance and thought suppression. These results are in line with a larger body of survey research in non-bereaved clinical and non-clinical samples supporting an association between rumination and cognitive and emotional avoidance (e.g., Cribb et al., 2006, Dickson et al., 2012, Giorgio et al., 2010, Kühn et al., 2012, Liverant et al., 2011, Moulds et al., 2007 and Wenzlaff and Luxton, 2003). Despite the consistent association between rumination and avoidance in survey investigations, few researchers have explicitly studied the link between rumination and behavioral – as opposed to self-report – indices of avoidance. Moreover, despite considerable evidence supporting an association between rumination and cognitive biases for general negative material, such as sad faces and negative words (for a review: Koster, Delissnyder, Derakshan, & de Raedt, 2011), few studies have addressed the relationship between rumination and biases for potentially threatening material. In one study that did investigate this topic, two groups of college students (low and high ruminators) were asked to engage in relaxation or rumination, after which they were instructed to imagine the death of a loved one (Giorgio et al., 2010). It was predicted that high ruminators would show a physiological response (i.e., heart rate increase) during the imagination exercise, after relaxation but not after rumination, which would indicate emotional suppression in the latter group. However, no differences were found between the relaxation and rumination conditions in high ruminators. Instead, the expected difference was detected in the low rumination group, suggesting that emotional suppression is only observed in individuals who do not ruminate regularly. Giorgio et al. (2010) explained this finding by arguing that the negative mood induction may have led high ruminators in the relaxation condition to ruminate, whereas low ruminators in this condition were less prone to do so. This study therefore provided preliminary evidence for a role of rumination in avoidance of the emotional experiences that are associated with the loss of a loved one. In another study, the hypothesis that grief-related rumination is associated with loss avoidance (RAH: Stroebe et al., 2007) in the presence of less-threatening negative material, was tested with an eye-tracking task in a sample of bereaved individuals (Eisma, Schut, et al., 2014). High and low ruminating individuals were asked to look repeatedly at two pictures (the deceased and a stranger), randomly combined with loss-related, negative and neutral words. High ruminators, compared to low ruminators, were shown to avoid loss cues (i.e., picture deceased + loss-related word), and showed attentional preference of general negative information (i.e., picture stranger + negative word) on extended presentation times (>1500 ms). Notably, these effects were maintained after correcting for symptoms of prolonged grief and depression. This study therefore provided evidence that rumination shows a unique association with conscious attentional avoidance of the loss. Given the potential theoretical and clinical implications of the function of rumination in bereavement, the relationship between rumination and loss avoidance needs to be further elucidated. Therefore, in the current investigation, the aim was to assess the link between rumination and an implicit measure of approach and avoidance, the Approach Avoidance Task (AAT; Rinck & Becker, 2007). In a typical AAT, individuals are instructed to respond with approach (i.e., pulling a joystick towards oneself; thereby making the stimulus on a computer screen larger) or avoidance (i.e., pushing a joystick away from oneself; thereby making the stimulus on a computer screen smaller) on the basis of a stimulus feature that is unrelated to the content or valence of the stimulus. In a classic application of the AAT, spider-fearful and non-spider fearful individuals were asked to respond to spider pictures or spider-free pictures, by pulling the picture towards themselves as fast as possible whenever the picture was in landscape format and pushing the picture away from themselves whenever the picture was in portrait format (Rinck & Becker, 2007). Thus, picture format served as a non-relevant cue. Trials were classified as congruent (pushing an aversive stimulus; pulling a non-aversive stimulus), or incongruent (pushing a non-aversive stimulus; pulling an aversive stimulus). The difference in reaction-times between congruent and incongruent trials, was interpreted as a measure of implicit approach and avoidance. If a person found it easier to push rather than pull a specific stimulus, this indicated an avoidance tendency for that stimulus. By contrast, if someone found it easier to pull than to push a particular stimulus, this indicated an approach tendency for that stimulus. In this particular investigation, spider-fearful individuals showed stronger avoidance tendencies for spider-pictures than participants with no fear of spiders. Since this initial research, the AAT has been successfully applied to investigate implicit approach and avoidance tendencies in many different areas, including post-traumatic stress disorder (Fleurkens, Rinck, & van Minnen, 2014), social anxiety (Heuer, Rinck, & Becker, 2007), and addiction (Cousijn, Goudriaan, & Wiers, 2011). In the present study, a sample of recently bereaved individuals was requested to complete an AAT using previously-developed stimuli (Eisma et al., 2014b and Gündel et al., 2003). There were three stimulus types: stimuli that represent the loss itself (i.e., picture deceased + loss word), stimuli that are loss-related but ambiguous (i.e., picture deceased + neutral word; picture stranger + loss word) and pictures that were non-loss-related and neutral (picture stranger + neutral word; puzzle picture + X's). For details on stimulus types see ‘Stimuli Development’ in the Methods section. Our hypotheses were based on previous eye-tracking research by Eisma, Schut, et al. (2014), which showed that bereaved high ruminators, compared to low ruminators, avoided loss-stimuli but no other stimulus types. We expected to be able to cross-validate these findings with a different measure of avoidance behavior, the AAT. Our main prediction was therefore: More grief-related rumination would be associated with stronger avoidance of loss cues, even when correcting for currently experienced distress (i.e., symptom levels of depression, posttraumatic stress, or prolonged grief).