Shorter communicationThe centrality of a loss and its role in emotional problems among bereaved people
Introduction
After the death of a loved one, a significant minority of people develops anxious and depressive symptoms or symptoms of complicated grief (CG). As currently defined, CG is a clinical condition that entails debilitating grief-reactions such as separation distress, difficulties accepting the loss, and difficulties moving on without the deceased that are present to the point of functional impairment for at least six months (Prigerson, Vanderwerker, & Maciejewski, 2008). Although categorical distinctions between normal/uncomplicated and complicated grief are made in the literature, there is also evidence that CG can be considered as the extreme end of a distribution that includes normal reactions to loss (Hogan, Worden, & Schmidt, 2004).
The treatment of CG requires knowledge of the factors involved in its development. In literature on posttraumatic stress-disorder (PTSD) there is growing interest in the concept “centrality of event”. This concept was put forth by Berntsen and Rubin, 2006, Berntsen and Rubin, 2007 and refers to the degree to which the memory of a traumatic life-event forms a reference point for the attribution of meaning to other events, a turning point in the life-story of the person, and a central component of a person's identity. Berntsen and Rubin postulated that heightened centrality of a traumatic event is associated with more severe PTSD because, among other reasons, it causes old and new non-traumatic events to become associated with the negative emotionality of the trauma in autobiographical memory maintaining a sense of current threat, leads to ruminations and worries, fuels negative cognitions about the self and the future, and causes the trauma to remain central to one's self-view and social roles.
Berntsen and Rubin (2006) constructed a 20-item and abbreviated 7-item version of the Centrality of Event Scale (CES) to measure the centrality of event concept. Using data from independent student samples they found CES-scores to be related to PTSD severity even when controlling for depression, anxiety, dissociation, and self-absorption (Berntsen and Rubin, 2006, Berntsen and Rubin, 2007). Findings support the validity of the CES and suggest that mechanisms tapped by this questionnaire are important for the understanding of individual differences in posttraumatic stress. CES-scores using pain as the stressful event were recently found to be correlated with pain intensity, life interference, and psychological distress among pain patients (Perri & Keefe, 2008) providing additional evidence for the importance of the centrality concept.
There are several reasons to assume that the degree to which bereaved individuals experience their loss as central is related to emotional problems following loss. First, clinical observations suggest that in people with difficulties recovering from loss, the loss continues to form a reference point for everyday inferences, a turning point in their lives, and an event that is central to their identity (Gluhoski, 1995). Secondly, it is plausible that heightened centrality of the loss-event interferes with grief-resolution, by blocking access to memory information that is unrelated to the lost person that is necessary for the revision of views of the self and future and for the engagement in activities and roles that are independent from the relationship with lost person (Boelen, van den Hout, & van den Bout, 2006). Third, the proposed importance of centrality of the loss-event accords with research showing that negative cognitions about the self and the future (Boelen, van den Bout, & van den Hout, 2003), continuing bonds to the deceased (Field, Gal-Oz, & Bonanno, 2003), and the degree to which self-defining memories are related to the deceased (Maccallum & Bryant, 2008) are associated with difficulties in recovery from loss.
To our knowledge, no studies have yet examined centrality of the loss-event in emotional problems following loss. The present study, conducted in the Netherlands, sought to do so. Specifically, this study had four aims. The first aim was to explore basic psychometric properties of the CES, including its internal consistency and factor structure among mourners. The second aim was to examine if centrality of the loss-event varied as a function of demographic variables (age, gender, education) and characteristics of the loss-event (kinship to the deceased, cause, time from loss). Berntsen and Rubin, 2006, Berntsen and Rubin, 2007 tested whether or not CES-scores differed between people who did and did not meet the A1 and A2 criteria of the DSM IV criteria for PTSD (APA, 2000). To our knowledge, no studies have yet explored other potentially meaningful subgroup differences in CES-scores.
The third aim was to examine how centrality of the loss relates to symptoms of CG and bereavement-related depression and PTSD, and to different variables that have been found to be related with loss-related psychopathology. A recent cognitive-behavioural model proposes and research has confirmed that three processes are involved in CG: (a) insufficient integration of the loss into the autobiographical memory base, (b) negative cognitions about the loss and its sequelae, and (c) avoidant responses (Boelen et al., 2006). In the present study, we examined to what extent CES-scores were correlated with measures tapping these processes. In addition, we examined to what extent CES-scores were associated with neuroticism and attachment style—variables that have been found to be related with post-loss psychopathology (Wijngaards-de Meij et al., 2007).
On the condition that CES-scores would be found to be related to the severity of CG, depression, and PTSD symptoms, the fourth aim was to examine the extent to which the centrality of the loss remained significantly associated with these symptoms, when controlling for the shared variance between these symptoms and the variance explained by the aforementioned correlates of CG—i.e., neuroticism, attachment, and indices of insufficient integration, negative thinking, and avoidance. In doing so, we sought to explore the incremental validity of the centrality concept. That is, to the extent that centrality of the loss is a corollary of cognitive–behavioural processes and personality factors we would not expect it to explain variance in CG, depression, and PTSD severity beyond these aforementioned correlates. Conversely, if centrality does explain unique variance in these outcomes, this would indicate that it has incremental validity.
Section snippets
Participants and procedure
Data were available from 254 bereaved individuals who participated in an ongoing research-program. Individuals were recruited through announcements on Dutch Internet sites about loss and grief that solicited people who lost a close relative to participate. People could express their willingness to participate by sending an e-mail to the present author, who subsequently sent a digital version (or, if so requested, paper version) of the questionnaire-package. Within a week after returning the
Descriptive statistics
Table 1 shows mean scores on the ICG-r, SCL-90 Depression scale, and PSS-SR. Scores were all in the subclinical range (cf. Arrindell and Ettema, 2003, Boelen, in press, Engelhard et al., 2007). Normality data indicated that SCL-90 Depression, PSS-SR, and GCQ scores were positively skewed. Therefore, these scores were log-transformed in all analyses described below. CES-scores were negatively skewed and were log-transformed after reflection. Transformations reduced non-normality of the variables.
Discussion
The current study investigated the role of centrality of the loss-event in emotional problems among bereaved people. A first main finding was that the 7-item CES is a reliable tool to assess centrality of the loss and represents one dimension. Findings accord with those of Berntsen and Rubin, 2006, Berntsen and Rubin, 2007 and indicate that the CES can be used across different groups confronted with different forms of adversity. A second main finding was that CES-scores did not vary as a
Acknowledgements
This research was supported by an Innovative Research Incentive Veni Grant (451-06-011) from the Netherlands Organization for Scientific Research (NWO) awarded to the author. Hans Pieterse is gratefully acknowledged for his help with the collection of data.
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