Rumination following bereavement: an overview
Keywords:
Rumination, avoidance, complicated grief, prolonged grief disorder, cognitive behavioural therapy, counsellingAbstract
AbstractThis contribution provides an overview of rumination (i.e., thinking repetitively and recurrently about negative events and/or negative emotions) in adjustment to bereavement. First, we summarise a growing literature on rumination and mental health outcomes of bereavement. Next, we compare two main theories explaining the maladaptive effects of rumination after loss, which hold conflicting implications for clinical practice. The Response Styles Theory (RST) states that rumination is a maladaptive confrontation strategy that perpetuates distress by increasing negative cognitions, impairing problem solving and instrumental behaviour and reducing social support. Conversely, the Rumination as Avoidance Hypothesis (RAH) holds that rumination may serve to avoid painful aspects of the loss, thereby hampering adjustment to bereavement. Crucially, while RST predicts that distraction reduces rumination, RAH predicts that loss exposure is more effective. We review evidence for RST and RAH and their clinical implications and conclude with a brief exploration of ways to reconcile these theories.
References
Bodnar JC, Kiecolt-Glase JK (1994). Caregiver depression after bereavement: chronic stress isn’t over when it’s over. Psychology and Aging, 9 372–380.
Boelen PA, van den Bout J, van den Hout MA (2006). Negative cognitions and avoidance in emotional problems after bereavement: a prospective study. Behaviour Research and Therapy 44 1657–1672.
Boelen PA, van den Hout MA, van den Bout J (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice 13 109–128.
Boelen PA, Reijntjes A, Smid GE (2016). Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement. Journal of Anxiety Disorders 41 65–72.
Boelen PA, van den Hout MA (2008). The role of threatening misinterpretations and avoidance in emotional problems after loss. Behavioural and Cognitive Psychotherapy 36 71–87.
Chen J, Liu X, Rapee RM, Pillay P (2013). Behavioural activation: a pilot trial of transdiagnostic treatment for excessive worry. Behaviour Research and Therapy 51 533–539.
Cribb G, Moulds ML, Carter S (2006). Rumination and experiential avoidance in depression. Behaviour Change 23 165–176.
Dickson KS, Ciesla JA, Reilly LC (2012). Rumination, worry, cognitive avoidance, and behavioral avoidance: examination of temporal effects. Behavior Therapy 43 629–640.
Eisma MC, Stroebe M, Schut H, Boelen PA, van den Bout J, Stroebe W (2012). Waarom is dit mij overkomen? Ontwikkeling en validatie van de Utrecht RouwRuminatieSchaal [Why did this happen to me? Development and validation of the Utrecht Grief Rumination Scale]. Gedragstherapie 45 369–388.
Eisma MC, Stroebe MS, Schut HA, Stroebe W, Boelen PA, van den Bout J (2013). Avoidance processes mediate the relationship between rumination and symptoms of complicated grief and depression following loss. Journal of Abnormal Psychology 122 961–970.
Eisma MC, Stroebe MS, Schut HA, van den Bout J, Boelen PA, Stroebe W (2014a). Development and psychometric evaluation of the Utrecht Grief Rumination Scale. Journal of Psychopathology and Behavioral Assessment 36 165–176.
Eisma MC, Schut HA, Stroebe MS, van den Bout J, Stroebe W, Boelen PA (2014b). Is rumination after bereavement linked with loss avoidance? Evidence from eye-tracking. PloS One 9 e104980.
Eisma MC, Schut HA, Stroebe MS, Boelen PA, van den Bout J, Stroebe W (2015a). Adaptive and maladaptive rumination after loss: A three-wave longitudinal study. British Journal of Clinical Psychology 54 163–180.
Eisma MC, Rinck M, Stroebe MS, Schut HA, Boelen PA, Stroebe W, van den Bout J (2015b). Rumination and implicit avoidance following bereavement: an approach avoidance task investigation. Journal of Behavior Therapy and Experimental Psychiatry 47 84–91.
Eisma MC, Boelen PA, van den Bout J, Stroebe W, Schut HA, Lancee J, Stroebe MS (2015c). Internet-based exposure and behavioral activation for complicated grief and rumination: a randomized controlled trial. Behavior Therapy 46 729–748.
Freud, S (1917/1957). Mourning and melancholia. In: J Strachey (ed). Standard edition of the complete works of Sigmund Freud. London: Hogarth, 152–170.
Giorgio JM, Sanflippo J, Kleiman E, Reilly D, Bender RE, Wagner CA, Alloy LB (2010). An experiential avoidance conceptualization of depressive rumination: three tests of the model. Behaviour Research and Therapy 48 1021–1031.
Ito T, Tomita T, Hasui C, Otsuka A, Katayama Y, Kawamura Y, Kitamura T (2003). The link between response styles and major depression and anxiety disorders after child-loss. Comprehensive Psychiatry 44 396–403.
Lejuez CW, Hopko DR, Acierno R, Daughters SB, Pagoto SL (2011). Ten year revision of the brief behavioral activation treatment for depression: revised treatment manual. Behavior Modification 35 111–161.
Liverant GI, Kamholz BW, Sloan DM, Brown TA (2011). Rumination in clinical depression: a type of emotional suppression? Cognitive Therapy and Research 35 253–265.
Li J, Stroebe M, Chan CL, Chow AY (2013). Guilt in bereavement: a review and conceptual framework. Death Studies 38 165–171.
Maciejewski PK, Zhang B, Block SD, Prigerson HG (2007). An empirical examination of the stage theory of grief. JAMA 297 716–723.
Martell CR, Addis ME, Jacobson NS (2001). Depression in context: strategies for guided action. New York: W.W. Norton.
Martin L, Tesser A (1996). Some ruminative thoughts. In: R Wyer (ed). Advances in social cognition (volume 9). Hillsdale, New Jersey: Lawrence Erlbaum Associates, 1–48.
Michael T, Halligan SL, Clark DM, Ehlers A (2007). Rumination in posttraumatic stress disorder. Depression and Anxiety 24 307–317.
Michael ST, Snyder CR (2005). Getting unstuck: the roles of hope, finding meaning, and rumination in the adjustment to bereavement among college students. Death Studies 29 435–458.
Morina N (2011). Rumination and avoidance as predictors of prolonged grief, depression, and posttraumatic stress in female widowed survivors of war. Journal of Nervous and Mental Disease 199 921–927.
Moulds ML, Kandris E, Starr S, Wong AC (2007). The relationship between rumination, avoidance and depression in a non-clinical sample. Behaviour Research and Therapy 45 251–261.
Nolen-Hoeksema S (2001). Ruminative coping and adjustment to bereavement. In: MS Stroebe, RO Hansson, W Stroebe, H Schut (eds). Handbook of bereavement research: consequences, coping, and care. Washington DC: American Psychological Association, 545–562.
Nolen-Hoeksema S, Davis CG (1999). “Thanks for sharing that”: ruminators and their social support networks. Journal of Personality and Social Psychology 77 801–814.
Nolen-Hoeksema S, McBride A, Larson J (1997). Rumination and psychological distress among bereaved partners. Journal of Personality and Social Psychology 72 855–862.
Nolen-Hoeksema S, Morrow J (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta Earthquake. Journal of Personality and Social Psychology 61 115–121.
Nolen-Hoeksema S, Parker LE, Larson J (1994). Ruminative coping with depressed mood following loss. Journal of Personality and Social Psychology 67 92–104.
Nolen-Hoeksema S, Wisco BE, Lyubomirsky S (2008). Rethinking rumination. Perspectives on Psychological Science 3 400–424.
O’Connor MF, Sussman TJ (2014). Developing the yearning in situations of loss scale: convergent and discriminant validity for bereavement, romantic breakup, and homesickness. Death Studies 38 450–458.
Papa A, Rummel C, Garrison-Diehn C, Sewell MT (2013). Behavioral activation for pathological grief. Death Studies 37 913–936.
Rinck M, Becker ES (2007). Approach and avoidance in fear of spiders. Journal of Behavior Therapy and Experimental Psychiatry 38(2) 105–120.
Schoofs H, Hermans D, Raes F (2010). Brooding and reflection as subtypes of rumination: evidence from confirmatory factor analysis in nonclinical samples using the Dutch Ruminative Response Scale. Journal of Psychopathology and Behavioral Assessment 32(4) 609–617.
Stroebe M, Boelen PA, van den Hout M, Stroebe W, Salemink E, van den Bout J (2007). Ruminative coping as avoidance. a reinterpretation of its function in adjustment to bereavement. European Archives of Psychiatry and Clinical Neuroscience 257 462–472.
Speckens AE, Ehlers A, Hackmann A, Ruths FA, Clark DM (2007). Intrusive memories and rumination in patients with post-traumatic stress disorder: a phenomenological comparison. Memory 15 249–257.
Tai R, Silver RC (1989). Coming to terms with major negative life events. In: JS Uleman, JA Bargh (eds). Unintended thought. New York: Oxford University Press, 351–382.
Torges CM, Stewart AJ, Nolen-Hoeksema S (2008). Regret resolution, aging, and adapting to loss. Psychology and Aging 23 169–180.
Treynor W, Gonzalez R, Nolen-Hoeksema S (2003). Rumination reconsidered: a psychometric analysis. Cognitive Therapy and Research 27 247–259.
Van der Houwe K, Stroebe M, Schut H, Stroebe W, van den Bout J (2010). Mediating processes in bereavement: the role of rumination, threatening grief interpretations, and deliberate grief avoidance. Social Science & Medicine 71 1669–1676.
Watkins ER, Mullan E, Wingrove J, Rimes K, Steiner H, Bathurst N, Scott J (2011). Rumination-focused cognitive-behavioural therapy for residual depression: phase II randomised controlled trial. The British Journal of Psychiatry 199 317–322.
Wenzlaff RM, Luxton DD (2003). The role of thought suppression in depressive rumination. Cognitive Therapy and Research 27 293–308.
Wisco BE, Sloan DM, Marx BP (2013). Cognitive emotion regulation and written exposure therapy for posttraumatic stress disorder. Clinical Psychological Science, 2167702613486630.
