Posttraumatic growth after the loss of a loved one in relation to ruminations and core beliefs

Introduction

Several empirical studies (e.g. Calhoun, Tedeschi, Cann, & Hanks, 2010; Taku, Calhoun, Cann, & Tedeschi, 2008; Taku, Tedeschi, & Cann, 2015) found that after difficult, traumatic situations, such as bereavement, individuals can experience not only negative consequences but also positive changes in terms of posttraumatic growth. Posttraumatic growth refers to how individuals can overcome adversity or trauma with improved psychological functioning, higher level of adaptation, and understanding of life (Tedeschi, Park, & Calhoun, 1998). It is important to stress that posttraumatic growth does not mean that an individual does not experience any pain or grief (Calhoun & Tedeschi, 2001), but that posttraumatic growth coexists with the distress caused by trauma (Tedeschi & Calhoun, 2004).

For posttraumatic growth to occur, an important factor seems to be the level to which a traumatic event disrupts or threatens core beliefs, related to the individual’s understanding of life, his or her meaningfulness of life, identity, and future, which all contribute to the assumptive world of the individual (Calhoun & Tedeschi, 2006; Cann, Calhoun, Tedeschi, & Solomon, 2010a; Janoff-Bulman, 2006; Lindstrom, Cann, Calhoun, & Tedeschi, 2013; Linley & Joseph, 2004). After the loss, the individual has to deal not only with the distress caused by trauma, but also with the disruption of core beliefs, which can eventually even increase the distress (Calhoun et al., 2010). While the individual is confronted with the disruption of core beliefs, he or she needs to cognitively process the event by repeatedly thinking about what happened, with the aim of understanding the traumatic situation (Cann et al., 2010a; Lindstrom et al., 2013). Initially, these repeated thoughts, ruminations, were described as entirely negative thoughts, related to less adaptive coping, more intensive grief, and a higher risk of depression (Nolen-Hoeksema, 2001). However, Nolen-Hoeksama and Davis (2004) later defined two types of ruminations. Intrusive ruminations happen when unwanted thoughts interfere with the individual’s cognitive world and are related to various negative consequences (e.g. “Thoughts about the event came to mind and I could not stop thinking about them”, Cann et al., 2011b). Deliberate ruminations happen when an individual voluntarily thinks about the trauma with the aim of understanding the trauma, changes caused by the trauma, and the consequences for the future (e.g. “I thought about whether I have learned anything as a result of my experience”, Cann et al., 2011b); these ruminations lead to constructive problem-solving and meaning-making (Calhoun et al., 2010; Cann et al., 2010; Nolen-Hoeksema & Davis, 2004). It seems that during the grieving process, both types of ruminations tend to coexist and oscillate (Ramos & Leal, 2013; Stroebe & Schut, 1999). People ruminate about the loss until they re-develop their assumptions of the world, schemes, values, and personal stories that have been threatened by the loss, so that they can become more resilient to another possible disruption of core beliefs. These results are experienced as posttraumatic growth (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 2004; Tedeschi, Park, & Calhoun, 1998).

The aim of our study is to gain a deeper understanding of the specifics of posttraumatic growth in bereaved individuals, and particularly how it relates to core beliefs disruption and different types of ruminations. Research studies in this field have been done mostly in the American population, with contradictory findings (e.g. Cann et al., 2010a; Lindstrom et al., 2013; Losavio et al., 2011; Taku & Oshio, 2015), and we are not aware of any similar study in Slovakia. Moreover, a partial goal of our study is to test the relationship between posttraumatic growth and the intensity of grief—which seems to be unclear—and to measure possible differences in posttraumatic growth based on the type of loss, relationship with the deceased, and time since loss.

Posttraumatic growth and ruminations

Several studies (e.g. Cann et al., 2010; Lindtrom et al., 2011; Taku & Oshio, 2015; Triplett, Tedeschi, Cann, Calhoun, & Reeve, 2011) have been conducted on the relationship between posttraumatic growth and ruminations, and clearly show that deliberate ruminations are an important predictor of posttraumatic growth. On the other hand, intrusive ruminations have been shown to be related to negative consequences, such as distress (e.g. Calhoun, Cann, Tedeschi, & McMillan, 2000; Cann et al., 2010a). Taku et al. (2008) found in a sample of bereaved university students that deliberate rumination soon after the event predicted higher posttraumatic growth. Intrusive ruminations have been shown to be positively predictive of distress, but not predictive of posttraumatic growth. However, in research by Lindstrom et al. (2013), both deliberate ruminations and intrusive ruminations positively predicted posttraumatic growth, while deliberate ruminations were more strongly related to posttraumatic growth. A clear positive relationship has been shown to exist between deliberate rumination and posttraumatic growth, so we formulated hypothesis H1: We assume that there is a positive relationship between deliberate ruminations and posttraumatic development in bereaved individuals. Based on the inconsistent findings about the relationship between intrusive ruminations and posttraumatic growth, research question Q1 was formulated: Is there a relationship between posttraumatic growth and intrusive ruminations in bereaved individuals? To better understand relationships between types of rumination and posttraumatic growth, research question Q2 was formulated: How do deliberate and intrusive ruminations predict posttraumatic growth?

Posttraumatic growth and core beliefs

Research studies in bereaved individuals suggest that the loss of a loved one can disrupt the individual’s core beliefs. The core component of the posttraumatic growth model is the premise that the process that eventually leads to posttraumatic growth starts with events which question or disrupt important aspects of assumptions about the world and therefore also disrupt core beliefs (Linley & Joseph, 2004). It has been shown that those who experience higher disruption of core beliefs also experience higher posttraumatic growth (Cann et al., 2010a, 2010b; Lindstrom et al., 2013). Similarly, research into stress-related growth after minor stressful events (Losavia et al., 2011) has shown that stress-related growth is also positively related to disruption of core beliefs. Challenges to our basic assumptions about the world, and therefore to our core beliefs, seem to be an important factor and perhaps also a causal predictor of posttraumatic growth. Therefore, we formulated hypothesis H2: We assume that the disruption of core beliefs positively predicts posttraumatic growth in bereaved individuals.

Core beliefs and ruminations

After the loss of a loved one, the disruption of assumptions about the world is likely to trigger other processes, such as deliberate and intrusive ruminations (Linley & Joseph, 2004; Calhoun & Tedeschi, 2006). Triplett, Tedeschi, Cann, Calhoun and Reeve (2012) and Losavio et al. (2011) found that a challenge to core beliefs is significantly related to both types of ruminations—deliberate and intrusive ruminations. Based on these research findings, we formulated two research hypotheses, H3a: We assume that disruption of core beliefs is positively related to deliberate ruminations in bereaved individuals. H3b: We assume that disruption of core beliefs is positively related to intrusive ruminations in bereaved individuals. To better understand the relationship between these types of ruminations and core beliefs, we formulated research question Q3: How do deliberate and intrusive ruminations predict core beliefs?

Grief and posttraumatic growth

Some studies have examined the relationship between grief and posttraumatic growth after the loss of a loved one and found the relationship to be positive (e.g. Ens & Bond, 2005; Hirooka, Fukahori, Ozawa, & Akita, 2017), while other investigations have indicated no relationship at all (Caserta, Lund, Utz, & Vries, 2009; Yilmaz & Zara, 2016). These results are contradictory both in relation to these variables and to the different types of loss. For example, a study by Büchi et al. (2007) found a positive relationship between grief and posttraumatic growth in grieving parents, while Martinčeková and Klatt (2017) found no relationship between grief and posttraumatic growth in grieving mothers. Based on these inconsistent research findings we formulated research question Q4: Is there a relationship between grief and posttraumatic growth after the loss of a loved one?

Posttraumatic growth and factors of loss

Several studies have focused on the differences in posttraumatic growth based on relationship with the deceased, time elapsed since loss, and type of loss. A study by Ogińska-Bulik (2014) found that people who experienced the loss of a parent or a sibling experienced greater positive change compared with individuals who had lost a child. Also, the loss of a brother or sister leads to higher posttraumatic growth than does the loss of a close friend. Cofini et al. (2014) found that posttraumatic growth was a little higher in individuals who had lost a close family member compared to those who had lost a friend or a lover. Armstrong and Shakespeare-Finch (2011) found highest posttraumatic growth in individuals who had lost a close member from a first-degree relationship (a spouse, parent, sibling, child), slightly lower posttraumatic growth in individuals who had lost a second-degree family member (a grandparent, niece, nephew) and lowest posttraumatic growth in individuals who had lost a friend. Based on these findings we formulated hypothesis H4: We assume that posttraumatic growth will be higher in individuals who have lost a first-degree family member than in those individuals who have lost a second-degree family member.

Posttraumatic growth is a process which can take some time, and therefore it is possible to assume that length of time since the loss might be related to higher posttraumatic growth. This assumption has been confirmed in some previous studies in individuals who had lost a loved one (e.g. Cofini et al., 2014; Yilmaz & Zara, 2016). In a study by Caserta et al. (2009), at least 20% of participants experienced medium to high posttraumatic growth between two and six months after the death of a loved one. However, time since loss alone was not related to posttraumatic growth, which could have been affected by the fact that the study comprised participants who had recently experienced a loss. Based on these unclear research findings, we formulated research question Q5: Is there a relationship between time since loss and posttraumatic growth after the loss?

The intensity of posttraumatic growth in bereaved individuals may be influenced by type of loss, that is, whether the loss was sudden or anticipated. Currier, Holland, and Neimeyer (2006) found that, after a loss caused by accident, murder, or suicide, young adults experienced higher levels of grief and had more problems finding meaning in their loss than individuals who had lost a close person for natural reasons. Currier, Mallot, Martinez, Sandy, & Neimeyer (2013) found that individuals who had lost a loved one due to an accident, suicide, or homicide, perceived higher positive changes in their life, despite simultaneously experiencing higher distress levels related to the traumatic event. These findings suggest that sudden loss may lead to higher distress and to higher posttraumatic growth at the same time. In view of these assumptions, we formulated research hypothesis H5: We assume that individuals experiencing a sudden loss experience higher posttraumatic growth than individuals experiencing the anticipated loss of a loved one.

Death of a loved one is often related to higher levels of posttraumatic growth in the domains of appreciation of life and relationships with others, and to relatively low posttraumatic growth in the domains of new possibilities and personal strength (Shakespeare-Finch & Armstrong, 2010; Taku et al., 2015). Similarly, a study by Ogińska-Bulik (2014) found highest posttraumatic growth in the domains relating to others and appreciation of life. A high level of posttraumatic growth in the relating to others domain has been found in other studies of bereaved individuals (Cofini et al., 2014; Currier et al., 2013; Taku & Oshio, 2015). Based on these research findings, we formulated hypothesis H6: We assume that the highest posttraumatic growth in bereaved individuals will be in the domains of relationships with others and appreciation of life.

Material and method

Methods

The questionnaire contained items relating to sociodemographic data (age, gender, and highest level of education completed) and data concerning the loss (time since loss, cause of loss, type of relationship to deceased and closeness of relationship to deceased).

To assess posttraumatic growth, we used the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), which is one of the most commonly used questionnaires to assess posttraumatic growth. The questionnaire is used in clinical praxis as well as in research, and there are many studies verifying its psychometric properties and factor structure (Tedeschi & Calhoun, 1996). The questionnaire consists of 21 items where the individual has to complete the statement “As a result of my loss I have experienced...” The individual rates the item on a 6-point Likert scale (0 = I did not experience this change; 5 = I experienced this change to a very great degree). The questionnaire consists of 5 scales: Relating to Others (7 items, e.g. “I have a greater sense of closeness with others.”); New Possibilities (5 items; e.g. “I developed new interests.”); Personal Strength (4 items, e.g. “I know better that I can handle difficulties.”); Spiritual Change (2 items, e.g. “I have a better understanding of spiritual matters.”); Appreciation of Life (3 items, e.g. “I changed my priorities about what is important in life.”). The internal consistency of the PTGI was very good for the whole questionnaire α = .96, and for the individual domains: relating to others α = .91; new possibilities α = .91, personal strength α = .84, spiritual change α = .68, appreciation of life α = .81.

The Event-related Rumination Inventory (ERRI; Cann et al., 2011b) was used to assess ruminations in the context of loss. The scale consists of 20 items assessed on a 4-point Likert scale from “not at all” to “often”. It consists of two subscales: deliberate rumination (e.g. “I thought about whether I could find meaning from my experience”) and intrusive rumination (e.g. “I thought about the event when I did not mean to”). The internal consistency of this scale was very good: α = .96 (intrusive rumination: α = .96, deliberate rumination: α = .94).

Core Bereavement Items (CBI1; Burnett et al., 1997) is a 17-item questionnaire measuring the intensity of grief reactions, specifically the emotions, thoughts, and behaviours relating to the loss of the loved one. Items are assessed on a 4-point Likert scale, for example “Do reminders of X such as photos, situations, music, places etc. cause you to feel sadness?” and “Do you find yourself thinking of reunion with X?”. The internal consistency of the questionnaire was found to be very good, α = .93.

Core Beliefs Inventory (CBI2; Cann et al., 2010b) was developed to assess changes in core beliefs due to a certain traumatic event. The scale consists of 9 items assessed on a 6-point Likert scale (from 0 – not at all to 5 – extremely; e.g. “Because of the event, I seriously examined my beliefs about the meaning of my life.”). The items are focused on disruption of core beliefs in the following areas: religious and spiritual beliefs, human nature, relationships with other people, meaning of life, and personal strengths and weaknesses. The reliability of the questionnaire was high, α = .90.

The data collection process

The questionnaire was distributed in electronic form and shared among various support groups for the loss of a loved one (e.g. the organizations “Kolobeh života” and “Viaticus” cooperated with us and distributed the questionnaire). Prior to completing the questionnaire, participants signed an informed consent form. They were informed that their participation was voluntary and that they could discontinue their participation at any time.

Results

The means, standard deviations, and correlations between the variables are presented in Table 1.

Hypothesis H1 was formulated as: “We assume that there is a positive relationship between deliberate ruminations and posttraumatic development in bereaved individuals” and research question Q1 was formulated as: “Is there a relationship between posttraumatic growth and intrusive ruminations in bereaved individuals?” The results of the Pearson correlational analysis showed that there was a strong positive relationship between deliberate ruminations and posttraumatic growth (r = .63) and a medium positive correlation between intrusive ruminations and posttraumatic growth (r = .41). Hypothesis H1 was supported.

To answer research question Q2 – How do deliberate and intrusive ruminations predict posttraumatic growth? – we used multiple regression analysis, the ENTER method. The results of the regression analysis show that both predictors explain 39% of variation in posttraumatic growth, (F(2, 137) = 45.84, p < .001). Deliberate rumination was shown to be a significant positive predictor of posttraumatic growth (β = .63; p < .001). The results of the regression analysis are shown in Table 2.

In hypothesis H2 we formulated the assumption that core beliefs disruption positively predicts posttraumatic growth in bereaved individuals. The results of the regression analysis show that disruption of core beliefs positively predicted posttraumatic growth in bereaved individuals (β = .59; p < .001). Hypothesis H2 was supported.

Hypothesis H3a was formulated in the following way: “We assume that disruption of core beliefs is positively related to deliberate ruminations in bereaved individuals.” Hypothesis H3b was formulated in the following way: “We assume that disruption of core beliefs is positively related to intrusive ruminations in bereaved individuals.” The correlational analysis showed that disruption of core beliefs was positively related to deliberate ruminations (r = .59) and that there was a medium relation to intrusive ruminations (r = .36). Hypotheses H3a and H3b were supported. To answer research question Q3 – How do deliberate and intrusive ruminations predict core beliefs? – we used multiple regression analysis, the ENTER method. The results of the regression analysis showed that both predictors explained 34% of variation in core beliefs, (F(2, 137) = 35.94, p < .001). Deliberate rumination was shown to be a significant positive predictor of core beliefs (β = .61; p < .001). The results of the regression analysis are shown in Table 3.

To analyse research question Q4: Is there a relationship between grief and posttraumatic growth after the loss of a loved one?, we used a correlational analysis. The results of the Pearson correlational analysis show that there was no significant relationship between time since loss and posttraumatic growth (r = -.063; p = .456).

Hypothesis H4 was formulated in the following way: “We assume that posttraumatic growth is higher in individuals who have lost a first-degree family member than in those individuals who have lost a second-degree family member.” The Shapiro-Wilk test of normality showed nonparametric data distribution so we selected a nonparametric U-test for the two independent groups. We compared individuals after the loss of a loved one from a first-degree relationship (loss of a child, parent, spouse, or sibling) and individuals after the loss of a loved one from a second-degree relationship (loss of a friend, uncle, cousin). The

results of the U-test (tab. 4) showed that posttraumatic growth was significantly higher in the group of individuals who had lost a close family member; there was a medium effect size r = .41). Hypothesis H4 was supported.

Hypothesis H5 was formulated in the following way: We assume that individuals experiencing a sudden loss experience higher posttraumatic growth than individuals experiencing the anticipated loss of a loved one. Based on the results of the Shapiro-Wilk test of normality, the distribution of data in the groups was parametric, so we used a parametrical T-test. Based on the findings (Table 5), we can say that posttraumatic growth was significantly higher in the group of people who had lost a loved one due to natural sudden loss. There was a medium effect size (d = .520). Hypothesis H5 was supported.

In hypothesis H6 we formulated the assumption that the highest posttraumatic growth would be in the domains relating to others and appreciation of life. We performed an error bars graph which shows differences between the individual means of the subscales based on a 95% confidence interval. Based on Figure 1 and the means of each subscale, we can conclude that the highest posttraumatic growth was found in the domains of appreciation of life (M = 3.26; SD = 1.44) and relating to others (M = 2.95; SD = 1.35). The lowest posttraumatic growth was found in the domain of spiritual change (M = 2.41; SD = 1.67). Personal strength (M = 2.71; SD = 1.35) and new possibilities (M = 2.52; SD = 1.47) had medium posttraumatic growth values. There were visible differences between the domains of posttraumatic growth.

Figure 1

Differences in domains of posttraumatic growth

Discussion

The main aim of this study was to explore posttraumatic growth after various types of loss in relation to ruminations and core beliefs. We will discuss our findings in the context of previous research findings and their implications.

Conclusion

The results of our study show that posttraumatic growth was related to both deliberate and intrusive ruminations, but was positively predicted by deliberate ruminations only. It also showed that disruption of core beliefs positively predicted posttraumatic growth. Core beliefs disruption was related to both types of ruminations, but was predicted by deliberate ruminations only. The results of our study may be beneficial to grief counsellors and therapists. Grief counselling should not just be aimed at eliminating the negative consequences and negative emotions caused by bereavement because these can serve as a stimulus for positive change and possible posttraumatic growth. Deliberate ruminations can help an individual to think about the loss and its consequences, restore core beliefs, and find meaning in the loss, and therefore they can lead to possible posttraumatic growth.