Angela Guarino 1, Grazia Serantoni 2 1 Department of Dynamic and Clinical Psychology, SAPIENZA–University of Rome, Rome, Italy 2 Department of Psychology, SAPIENZA–University of Rome, Rome, Italy

GRIEF AND BEREAVEMENT

Grief and bereavement: an overview

•  For parents, losing a child is a deep trauma that requires a cognitive and emotional redefinition –more or less adaptive – of life functions and relationships (Two-Track Model of Bereavement):

(Rubin & Malkinson, 2001)

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Two-Track Model of Bereavement (Rubin & Malkinson, 2001)

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TRACK 1: FUNCTIONING Anxiety Depressive affect and cognitions Somatic concerns Symptoms of a psychiatric nature Familial relationships General interpersonal relations Self-esteem and self-worth Meaning structure Work Investment in life tasks

TRACK 2: RELATIONSHIP TO THE DECEASED Imagery and memory Emotional distance Positive and/or negative affect Preoccupation with loss Idealization Conflict Features of loss process Impact on self-perception Memorialization of loss

Grief and bereavement: definitions

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•  The grief of a parent corresponds to distress and suffering related to loss, with individual differences in duration, intensity, expressions: the natural feelings associated with grief include sadness, anger, helplessness, despair, denial, disbelief, shock and guilt.

(Stroebe, Hansson, Stroebe, & Schut, 2001; Guarino, 2006; Para, 2009)

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•  Experiencing and elaborating the grief is fundamental for regaining emotional well-being and growing innerly: the group psychotherapy – with its possibility of being therapist to the very members who make it up – is the most widely used therapeutic instrument for helping bereaved parents not to develop complicated grief.

(Stroebe, Hansson, Stroebe, & Schut, 2001; Mancini & Bonanno, 2006;

Guarino, 2006; Para, 2009)

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Psychotherapeutic groups for bereaved parents: psychological topics of proximal outcomes

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ENHANCED SOCIAL RESOURCES Better relationships with and increased closeness to family members and friends New relationships with friends and confidants Increases in social support networks

NEW COPING SKILLS Longer term enhanced cognitive and behavioural coping skills in these areas: • search for meanings; • logical analysis; • positive reappraisal; • acceptance.

COGNITIVE AND BEHAVIOURAL COPING STRATEGIES

Psychotherapeutic groups for bereaved parents: theoretical approaches for gaining proximal outcomes

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ENHANCED SOCIAL RESOURCES Better relationships with and increased closeness to family members and friends New relationships with friends and confidants Increases in social support networks

NEW COPING SKILLS Longer term enhanced cognitive and behavioural coping skills in these areas: • search for meanings; • logical analysis; • positive reappraisal; • acceptance.

Reducing distress and detecting automatic thoughts

Helping bereaved parents regaining interests and relationships through discussion

of consequence of feelings and emotions related to the loss

Improving bereaved parents’ immediate adaptation to their life situation

IN A (SUPPORTIVE) PSYCHODYNAMIC THEORETICAL FRAMEWORK, HIGH USE OF INTERPERSONAL AND COGNITIVE-BEHAVIORAL TECHNIQUES

Psychotherapeutic groups for bereaved parents: psychological topics of ultimate outcomes

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ENHANCED PERSONAL RESOURCES Increased self-esteem and self-efficacy Greater independence and maturity More compassion, empathy and tolerance Greater appreciation of life, more life satisfaction and well-being Changes in goals, values and world view Better communication skills and increased ability to resolve conflicts Increased altruism

Psychotherapeutic groups for bereaved parents: theoretical approaches for gaining ultimate outcomes

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ENHANCED PERSONAL RESOURCES Increased self-esteem and self-efficacy Greater independence and maturity More compassion, empathy and tolerance Greater appreciation of life, more life satisfaction and well-being Changes in goals, values and world view Better communication skills and increased ability to resolve conflicts Increased altruism

Reducing automatic thoughts for diminishing the power associated with them

Establishing norms, encouraging process reviews, and making here‐and‐now interventions

Enhancing bereaved parents’ insight about repetitive intrapsychic and interpersonal conflicts and trauma associated with loss through

balancing tension and comfort

THROUGH A (INTERPRETATIVE) PSYCHODYNAMIC THEORETICAL APPROACH, OCCASIONAL USE OF INTERPERSONAL AND COGNITIVE-BEHAVIORAL TECHNIQUES

Psychotherapeutic group for bereaved parents: how it works

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•  The psychotherapeutic group for bereaved parents which is held in Lefebvre D’Ovidio Foundation Onlus (Rome) is a psychodynamically oriented group (homogeneous by type of loss and heterogeneous by phase of mourning; with fortnightly two-hour sessions) that includes use of cognitive and interpersonal techniques.

This group is open to receive new parents that can be sent by both hospitals and private.

•  As shown by the part of process-outcome [for evaluating the effectiveness of the aforementioned psychotherapeutic groups for bereaved parents (Guarino & Serantoni, 2006)] research’s results concerning the peculiar group processes activated by parents who have lost a child (due to illness or accident), the therapeutic factors detectable in group are:

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•  creation of solidarity, •  overcoming social isolation, •  possibility of mirroring, •  positive impact of peer pressure, •  mutual support and feedback, •  building of new skills, •  exchange and experimentation through vicarious

families, •  increasing of hope, •  enhancement of reflective function.

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•  Statistical analysis of mean differences (one-way ANOVA) [Shapiro-Wilk test for normality of samples <50 shows p-values greater than 0.05, then the null hypothesis that the data are normally distributed has not been rejected], on the measured variables concerning the peculiar group processes, point out, inter alia, higher levels of Personal Growth in fathers and those who haven’t experienced a double loss.

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•  Fathers have better Working Capacity and show higher levels of Awareness of Interpersonal Impact.

•  Cohesion’s facets appears to be the most important group factor.

•  With regard to therapeutic factors, women show stronger Commitment and Instillation of Hope but, at the same time, feelings of Conflict.

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FREQUENCIES: Therapeutic factors

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MANOVA results: Therapeutic factors*indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig.

95% Confidence Interval

Partial Eta

Squared

Noncent. Paramet

er Observed Powerb

Lower Bound

Upper Bound

Instillation_Hope FATHERS 29,000 4,359 6,653 ,022 10,245 47,755 ,957 6,653 ,890

MOTHERS 27,000 4,359 6,194 ,025 8,245 45,755 ,950 6,194 ,854

Secure_Emotional Expression

FATHERS 37,000 4,359 8,488 ,014 18,245 55,755 ,973 8,488 ,972

MOTHERS 32,000 4,359 7,341 ,018 13,245 50,755 ,964 7,341 ,931

Awareness_ Interpersonal_Impact

FATHERS 28,000 2,517 11,126 ,008 17,172 38,828 ,984 11,126 ,998

MOTHERS 27,000 2,517 10,729 ,009 16,172 37,828 ,983 10,729 ,997

Social_Learning FATHERS 17,000 ,577 29,445 ,001 14,516 19,484 ,998 29,445 1,000

MOTHERS 17,000 ,577 29,445 ,001 14,516 19,484 ,998 29,445 1,000

[TIME_permanence INgroup=1]

5,000 ,816 6,124 ,026 1,487 8,513 ,949 6,124 ,847

[TIME_permanence INgroup=2]

5,000 ,816 6,124 ,026 1,487 8,513 ,949 6,124 ,847

b. Computed using alpha = ,05

FREQUENCIES: Group climate

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MANOVA results: Group climate*indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig.

95% Confidence Interval

Partial Eta Squared

Noncent. Parameter

Observed Powerb

Lower Bound

Upper Bound

Engagement FATHERS 26,000 1,528 17,021 ,003 19,428 32,572 ,993 17,021 1,000

MOTHERS 20,000 1,528 13,093 ,006 13,428 26,572 ,988 13,093 1,000

Avoidance FATHERS 12,000 1,528 7,856 ,016 5,428 18,572 ,969 7,856 ,953

MOTHERS 13,000 1,528 8,510 ,014 6,428 19,572 ,973 8,510 ,972

b. Computed using alpha = ,05

FREQUENCIES: Group Cohesion

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MANOVA results: Group Cohesion*indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig.

95% Confidence Interval Partial

Eta Squared

Noncent. Paramet

er Observed Powerb

Lower Bound

Upper Bound

Mutual_Stimulation Effect

FATHERS 12,000 ,577 20,785 ,002 9,516 14,484 ,995 20,785 1,000 MOTHERS 8,000 ,577 13,856 ,005 5,516 10,484 ,990 13,856 1,000

[TIME_permanence INgroup=1]

5,000 ,816 6,124 ,026 1,487 8,513 ,949 6,124 ,847

[TIME_permanence INgroup=2]

4,667 ,667 4,000 ,049 -,202 5,535 ,889 4,000 ,565

Commitment_To Group

FATHERS 16,000 ,577 27,713 ,001 13,516 18,484 ,997 27,713 1,000 MOTHERS 15,000 ,577 25,981 ,001 12,516 17,484 ,997 25,981 1,000

Compatibility_Of Group

FATHERS 15,000 1,155 12,990 ,006 10,032 19,968 ,988 12,990 1,000 MOTHERS 15,000 1,155 12,990 ,006 10,032 19,968 ,988 12,990 1,000

b. Computed using alpha = ,05

FREQUENCIES: Therapeutic Alliance

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MANOVA results: Therapeutic Alliance *indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig.

95% Confidence Interval

Partial Eta

Squared

Noncent. Paramet

er Observed Powerb

Lower Bound

Upper Bound

Patient_Working_Capacity FATHERS 19,000 2,082 9,127 ,012 10,043 27,957 ,977 9,127 ,984

MOTHERS 12,000 2,082 5,765 ,029 3,043 20,957 ,943 5,765 ,812

Patient_Commitment FATHERS 20,000 1,000 20,000 ,002 15,697 24,303 ,995 20,000 1,000

MOTHERS 20,000 1,000 20,000 ,002 15,697 24,303 ,995 20,000 1,000

Group_Understanding Involvement

FATHERS 19,000 1,155 16,454 ,004 14,032 23,968 ,993 16,454 1,000

MOTHERS 17,000 1,155 14,722 ,005 12,032 21,968 ,991 14,722 1,000

b. Computed using alpha = ,05

Psychotherapeutic group for bereaved parents: outcome results

•  The aim of this presentation is showing part of results of the aforementioned research, concerning the changes in the level of symptoms related to the loss and in the outlook on life of 12 bereaved parents joining the group [8 women, 4 men; age: µ=57, s.d.=8,78; permanence in group (in month): µ=38,18, s.d.=19,78].

•  Shapiro-Wilk test for normality of samples <50 shows p-values greater than 0.05, then the null hypothesis that the data are normally distributed has not been rejected.

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•  The selected measured variables and administered tests are:

•  Grief (HGRC: Hogan, Greenfield, & Schmidt, 2001): Despair, Panic Behaviour, Blame and Anger, Disorganization, Detachment, Personal Growth;

•  Changes in outlook (CiOQ: Joseph et al., 2005): Positive Changes in Outlook, Negative Changes in Outlook;

•  Complicated grief (ICG: Prigerson et al., 1995): level of maladaptive symptoms of loss.

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FREQUENCIES: Grief variables

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•  We've checked the variable "temporal distance from death of child": the improvements are recognized in parents with profiles of complicated grief and medium-high temporal distance from the death of their children as well as parents who have just joined the group after the loss, thus avoiding the risk of complicated grief.

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FREQUENCIES: Grief level and Outlook on Life

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MANOVA: Grief variables*indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig. 95% Confidence Interval

Lower Bound Upper Bound Despair FATHERS 17,000 5,521 3,079 ,022 3,491 30,509

MOTHERS 27,750 3,904 7,108 ,000 18,198 37,302 [TIME_permanence INgroup=1]

15,750 6,762 2,329 ,059 -,795 32,295

Panic Behaviour

FATHERS 16,000 5,350 2,991 ,024 2,908 29,092 MOTHERS 27,500 3,783 7,269 ,000 18,243 36,757 [TIME_permanence INgroup=1]

13,000 6,553 1,984 ,045 -3,034 29,034

Personal Growth

FATHERS 35,500 3,651 9,722 ,000 26,565 44,435 MOTHERS 40,500 2,582 15,686 ,000 34,182 46,818

Blame_Anger FATHERS 10,500 3,894 2,696 ,036 ,971 20,029 MOTHERS 13,500 2,754 4,902 ,003 6,762 20,238 [TIME_permanence INgroup=1]

12,500 4,770 2,621 ,040 ,829 24,171

Detachment FATHERS 9,500 1,882 5,048 ,002 4,895 14,105 MOTHERS 15,000 1,331 11,272 ,000 11,744 18,256 [TIME_permanence INgroup=1]

13,000 2,305 5,640 ,001 7,360 18,640

Disorganization FATHERS 8,000 2,638 3,033 ,023 1,545 14,455 MOTHERS 14,500 1,865 7,774 ,000 9,936 19,064 [TIME_permanence INgroup=1]

10,000 3,231 3,095 ,021 2,095 17,905

MANOVA: Grief level and Outlook on Life*indipendent variables

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Parameter Estimates

Dependent Variable B Std. Error t Sig.

95% Confidence Interval

Lower Bound Upper Bound CiO_positive FATHERS 40,000 5,406 7,399 ,000 26,771 53,229

MOTHERS 45,250 3,823 11,837 ,000 35,896 54,604

CiO_negative FATHERS 34,500 7,603 4,537 ,004 15,895 53,105

MOTHERS 25,750 5,376 4,789 ,003 12,594 38,906

[TIME_permanence INgroup=1]

32,750 9,312 3,517 ,013 9,964 55,536

Grief_level FATHERS 25,500 8,972 2,842 ,029 3,546 47,454

MOTHERS 32,500 6,344 5,123 ,002 16,976 48,024

[TIME_permanence INgroup=1]

33,000 10,989 3,003 ,024 6,112 59,888

Brief conclusions and considerations

•  The statistical analysis confirmed the differences in coping the trauma between fathers and mothers (one-way ANOVA and MANOVA): the psychotherapist who conducts the group psychotherapy should take into account this element, already highlighted in the international literature.

(Bonanno & Mancini, 2001; Guarino, 2006)

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•  The analysis of mean differences (one-way ANOVA) point out, inter alia, higher levels of Personal Growth and lower levels of Blame and Anger in fathers and in parents who have a higher permanence in group.

•  The statistical analysis confirm that a time of permanence in group more than 12 months has a positive effect on the negative aspects associated with grief.

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•  In agreement with the international literature, a medium-high time spent in group seems to: protect, balancing the outlook on life and improving a Positive Changes in Outlook, parents with medium-high risk of complicated grief; allow an important improvement in symptoms of loss in parents with general risk of complicated grief.

(Bonanno & Mancini, 2001; Kazak & Noll, 2004; Para, 2009)

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•  Ultimately, bereaved parents, left alone, may develop complicated grief that could lead meaningful and persistent social and/or psychological difficulties (development of severe psychopathologies, broken families, psychological problems in surviving siblings, job loss, etc.), with a high social costs: the spread of programs of group psychotherapy (effective and less expensive than individual interventions) may be the answer.

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Bibliography

•  1. Rubin S.S., Malkinson R. Parental response to child loss across the life cycle: clinical and research perspectives. In: Stroebe M.S., Hansson R.O., Stroebe W., Schut H., editors. Handbook of bereavement research: Consequences, coping, and care. Washington, D.C: American Psychological Association; 2001. cap. 10, pp. 219-240.

•  2. Para E.A. Group Counseling for Complicated Grief: A Literature Review. Grad. J. Couns. Psy., Vol. 1, Iss. 2 (2009), Art. 10.

•  3. Stroebe M.S., Hansson R.O., Stroebe W., Schut H., editors. Handbook of bereavement research: Consequences, coping, and care. Washington, D.C: American Psychological Association; 2001.

•  4. Mancini A.D., Bonanno G.A. Bereavement. In: Fisher J.E., O’Donohue W.T., editors. Practitioner’s guide to evidence-based psychotherapy. New York: Springer; 2006. cap. 11, pp. 122-130.

•  5. Guarino A. Psiconcologia dell’età evolutiva. La Psicologia nelle cure dei bambini malati di cancro. Trento: Erickson; 2006.

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Bibliography

•  6. Guarino A., Serantoni G. Psychometric instruments for measuring and preventing the risk of complicated grief in bereaved parents. Int. J. Psy., 2008; volume 43, issue 3/4.

•  7. Hogan N.S., Greenfield D.B., Schmidt L.A. Development and validation of the Hogan Grief Reaction Checklist. Death studies, 2001; 25(1), 1-32.

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•  11. Piper W.E., Marrache M., Lacroix R., Richardson A.M., Jones, B.D. Cohesion as a basic bond in groups. Human Relations, 1983; 36, 93-108.

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