Rumination following bereavement: Assessment, working mechanisms and intervention

Abstract

We aimed to gain better understanding of rumination, a risk factor for poor bereavement outcome, so it can be targeted more effectively in therapeutic interventions. We defined grief-related rumination as thinking repetitively and recurrently about the causes and consequences of a loss and loss-related negative emotions. Although many researchers regarded rumination after bereavement as a maladaptive confrontation strategy, others have recently claimed that rumination could serve as cognitive avoidance of painful aspects of a loss, thereby contributing to grief complications. Crucially, these different conceptualizations of rumination lead to diverging guidelines for clinical practice. If rumination is a confrontation process, then positive distraction may reduce it, whereas if it is avoidance, then exposure therapy may be effective. A research project consisting of three integrated parts was conducted to clarify the role of rumination after loss. First, we developed and validated a new scale for grief-related rumination, the Utrecht Grief Rumination Scale (UGRS). Two cross-sectional and one longitudinal survey study showed that a correlated five-factor model fit the UGRS data best and that this factor structure showed cross-cultural equivalence. Furthermore, the reliability and discriminant, convergent, divergent, concurrent and predictive validity of the UGRS and its five subscales was substantially supported. Second, we set out to clarify the association between rumination and approach and avoidance processes. We first aimed to test if avoidance potentially mediates the relationship between rumination on and post-loss mental health problems, by conducting a three-wave longitudinal survey study in a bereaved sample. One major finding of this study was that both avoidance of internal experiences and thought suppression were potential mediators of the relationship between grief rumination and complicated grief symptom change. Next, we conducted two laboratory studies. In a first study, we investigated attention patterns of bereaved persons high and low on rumination for neutral, negative, loss-related and loss-reality cues using eye-tracking. Results indicated high ruminators, relative to low ruminators, consciously diverted attention away from loss-reality stimuli, whilst showing attentional preference for general negative (and neutral) stimuli. In a second study, the link between rumination and implicit approach and avoidance was tested with an Approach Avoidance Task. Results showed rumination predicted implicit avoidance of loss-reality stimuli, but not approach or avoidance of loss-related or neutral stimuli. In both studies, results were similar after controlling for concurrently experienced distress. Third, we conducted a waiting-list randomized controlled trial in sub-clinically bereaved individuals to investigate the effectiveness of internet-delivered exposure and behavioral activation in reducing rumination and loss-related distress. Major findings were that exposure strongly reduced grief rumination and complicated grief relative to a waiting list group at post-test and follow-up in completers and in intention-to-treat analyses. The effectiveness of behavioral activation was not substantially supported in completers analyses, but it did yield large reductions in levels of grief rumination and complicated grief across time-points in the intention-to-treat analyses. In conclusion, findings support the hypothesis that grief rumination serves to avoid painful aspects of the loss. Furthermore, exposure therapy is a potentially effective way to reduce rumination and post-loss distress.