A study examining the maintenance of complicated grief following violent loss with a special focus on civil conflict

: a cognitive perspective

Abstract

Bereavement is a highly distressing and disruptive experience. Grief, particularly when traumatic, is associated with an increased risk of major depressive disorder (MDD), posttraumatic stress disorder (PTSD) and complicated grief (CG). Unlike acute grief, CG is a persistent, intense and impairing condition diagnosed when distressing and disabling grief has persisted for at least six months. There is expanding research on CG among several vulnerable populations; however, CG and the mechanisms which maintain it have scarcely been examined among those who have been bereaved following conflict violent loss (CVL). This thesis presents two narrative reviews and two studies designed to develop our understanding of the cognitive factors associated with CG following CVL and to determine whether the addition of conflict to violent loss (VL) results in distinctive cognitions that may serve to maintain CG in this vulnerable sub-population.

Chapter 3 presents a narrative review of the literature on the role of cognitive factors in the development and maintenance of CG in adults following VL. In total, 24 papers were included in the final review. Findings highlight the adaptive function of meaning-making in the grief process and the maladaptive roles that cognitions (i.e., avoidance, rumination, and negative appraisals), as well as yearning, play in the relationship between meaning-making and CG following VL. Further evidence suggests that it may not be VL per se that results in CG but the failure to make sense of such losses, which may stem from two distinct but overlapping pathways: cognitive avoidance and rumination.

Chapter 4 presents a narrative review of the literature on the role of cognitive factors in the development and maintenance of CG adults following CVL. In total, 10 papers were included in the final review. Findings are consistent with literature implicating both rumination and avoidance in maintaining CG associated with CVL. However, there was a cultural effect on the performance of these items, which may need consideration. Global negative beliefs and negative assumptive worldviews were also strongly associated with CG in this population, as were guilt/responsibility appraisals, which were particularly elevated in males. Whilst the prevalence of CG reported in these studies was significantly varied (8%-82%), there is evidence that those suffering from CVL are at an increased risk for developing CG and comorbid PTSD.

Chapter 5 presents the results from study 1 which investigated the cognitive factors relevant to the development and maintenance of CG across two loss groups (CVL and VL). Sample comprised of 74 adults bereaved following VL associated with conflict, homicide, suicide, and accident. Correlation analysis as well as analysis of variance (ANOVA) tests were used to analyse the data. Results demonstrate that conflict appears to add an additional layer of complexity to VL, resulting in significantly increased severity of CG symptomology and higher levels of comorbid PTSD and Depression, which showed no signs of remission over time.

Chapter 6 presents the results from study 2 which used the same sample data used in study 1. Results from mediation analysis suggest that specific cognitive maintenance factors (Loss of Self and Life, Loss of Relationship and Future, Fear of Losing Connection to The Deceased, Avoidance, Proximity Seeking, Injustice Rumination, Negative Interpretation of Others and Safety in Solitude) may have a stronger hold in maintaining the relationship between CVL and CG.

In conclusion, the data demonstrate that CG occurs in a significantly high portion of CVL survivors many years post-loss and that a distinct set of cognitive factors mediate the severity of their grief reactions. CVL survivors face unique challenges, including a strong sense of injustice and a lifelong struggle with mental health issues, including CG Depression and PTSD. These findings have implications for our understanding of sub-populations suffering from CG and have clinical importance for treating those bereaved following CVL.

Date of Award	Dec 2024
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	Northern Ireland Department for the Economy
Supervisor	Michael Duffy (Supervisor)