The Unfinished Business in Bereavement Scale (UBBS): Development and Psychometric Evaluation

Abstract

Although unresolved issues with the deceased are often targeted in bereavement interventions, understanding of this construct has been hampered by the lack of a psychometrically validated scale to assess it. To address this gap, the Unfinished Business in Bereavement Scale (UBBS) was developed and tested in two samples of bereaved adults (n = 292 and 168). In exploratory and confirmatory factor analyses, the UBBS was found to be composed of two related factors. Items tapping into Unfulfilled Wishes pertained to unspoken affirmations or missed opportunities with the deceased. These experiences often emerged in loving relationships and only became problematic when accompanied by high levels of distress. In contrast, Unresolved Conflict pertained to unaddressed disputes or indiscretions. It primarily occurred in relationships characterized by anxiety and conflict and conferred risk for prolonged grief reactions even when endorsed at moderate levels. Other findings strongly supported the internal consistency, concurrent validity, and incremental validity of the UBBS. Unfinished business and meaning made of loss together accounted for 50-60% of the variance in prolonged grief symptoms. Implications for clinical practice and future research are discussed.

There is a need to identify risk factors that can differentiate grievers with chronic and prolonged symptomatology—such as those exhibiting Prolonged Grief Disorder (PGD)—from those with a more typical, resilient trajectory through the bereavement process (Bonanno et al., 2002; Prigerson, Vanderwerker, & Maciejewski, 2008). One widely discussed risk factor in theoretical and clinical literature is unfinished business, which refers to unexpressed or unresolved issues between the griever and the deceased (Holland, Thompson, Rozalski, & Lichtenthal, 2013). There has been little empirical examination of this construct, though recent work has noted that the presence of unfinished business in bereavement and distress related to it are associated with poorer self-reported physical and mental health (Klingspon, Holland, Neimeyer, & Lichtenthal, 2015). The present study aims to expand upon this work by proposing and psychometrically testing a new self-report measure of unfinished business called the Unfinished Business in Bereavement Scale (UBBS).

The presence of unfinished business may indicate a problem with sustained attachment to the deceased. From an attachment theory perspective, expectations that we form early in life impact the way that we relate to others throughout the lifespan, including adult attachment figures such as partners and spouses (Bonanno et al., 2002, Stroebe, 2002; Van Doorn et al., 1998). Separation distress, a defining feature of PGD, is conceptualized by some as stemming from difficulties in maintaining an enduring emotional bond with the deceased (Field, Gao, & Paderna, 2005; Klass, Silverman, & Nickman, 1996). Though early theorists believed this continuing bond with the deceased was problematic (e.g., Bowlby, 1973, 1980; Freud, 1917/1957), more modern understandings of loss suggest that the specific nature of the continuing bond largely determines if it will be experienced as distressful, comforting, or benign (Fraley & Shaver, 1999; Klass et al., 1996; Klass & Steffen, 2018; Neimeyer, Baldwin, & Gillies, 2006). Unfinished business may indicate a problem in this enduring relationship to the deceased, given its association with both stronger continuing bonds and greater prolonged grief symptomatology (Klingspon et al., 2015).

Unfinished business is often a target for treatment in commonly implemented bereavement interventions, despite the lack of research in this area. For instance, evidence-based Complicated Grief Treatment uses imaginal dialogues and letters to the deceased to give patients a chance to resolve aspects of the relationship that are perceived as unfinished (Shear, Frank, Houck, & Reynolds, 2005). In addition, “empty chair” exercises, whereby a bereaved person is encouraged to have emotionally-evocative conversations with the deceased (who is imagined to be sitting in an empty chair), have been shown to provide individuals with some sense of resolution (Greenberg, Rice, & Elliott, 1993; Paivio & Greenberg, 1995).

Despite the clinical salience of unfinished business, few tools exist to assess it. Researchers have attempted to assess unfinished business using the ‘empty chair’ technique to assess non-resolution of unfinished business in bereaved spouses (Field & Horowitz, 1998). Following this evocative exercise, participants were asked to rate their degree of perceived adjustment to unresolved issues (e.g., self-blame, blame toward deceased, helplessness, non-acceptance of the loss) using a 13-item questionnaire designed for the study (Field & Horowitz, 1998). Notwithstanding the face validity of this approach, ultimately it was found to be highly distressing to participants (e.g., over 75% wept) and required thorough debriefing and follow-up, making it impractical in many settings.

Another study employed a one-item measure to assess unfinished business, and this face-valid, self-report measure was found to correlate with related constructs in predicted ways (Klingspon et al., 2015). Despite the efficiency of this one-item scale, unfinished business may represent a multidimensional construct that cannot be fully assessed with a single item. The only existing multi-item scale of unfinished business is the Unfinished Business Resolution Scale (UFB-RS; Singh, 1994). However, this scale would be difficult to administer to a broad range of bereaved individuals, given that its items were developed primarily for relationships with the living and are specifically geared toward those who have already reported problems (e.g., I have come to terms with not getting what I need or want from this person).

The present study seeks to overcome the limitations of previous assessment tools by developing and testing a measure of unfinished business in bereavement that can be administered quickly and easily. In particular, this study has seven aims:

1. To develop and refine a pool of items to assess unfinished business in bereavement.

2. To conduct an exploratory factor analysis (EFA) to examine the factor structure of these items.

3. To conduct a confirmatory factor analysis (CFA) in a second sample to examine the generalizability of the findings from the EFA.

4. To explore associations between UBBS scores, demographic factors (e.g., age, gender, family income), and circumstances of the loss (e.g., relationship to the deceased, cause of death).

5. To test the concurrent validity of the UBBS by examining the associations between scores on this UBBS and related constructs (e.g., PGD symptoms, meaning made of the loss, problematic attachment).

6. To test the incremental validity of the UBBS by examining its unique associations with PGD symptoms after statistically controlling for related constructs and potential confounding variables.

7. To establish optimal cut-scores on the UBBS (and any confirmed subscales) for identifying individuals with problematic unfinished business.

We hypothesized that the validated measure would be multifactorial would will be broadly representative of the themes that have emerged in previous examinations of unfinished business (Klingspon et al., 2015; Masterson et al., in press). We expected that those with higher scores on this unfinished business measure to report more severe prolonged grief symptoms, less meaning made of the loss, higher attachment anxiety, and lower relationship quality with the deceased.

Methods

Participants and Procedure

Participants were undergraduate psychology students at two large state-funded universities in the Southern and Southwestern regions of the U.S. Students were recruited via a university-sponsored online system (i.e., SONA) and received course credit for completing the study. An online survey tool (i.e., Qualtrics) was used to administer the UBBS and other assessment tools. To be eligible for the study, participants needed to (1) report having a loved one die in the past 2 years and (2) be 18 years or older. The average participant was a young adult woman who had lost a friend or extended family member to natural causes. Both samples were diverse with respect to ethnicity and economic background. Additional details about the samples are provided in Table 1.

Table 1.

Demographic Information and Circumstances of the Loss

	Southern Sample (n = 292)	Southwestern Sample (n = 168)
Age:	Mean = 21.5, SD = 6.1	Mean = 20.3, SD = 3.0
Sex:	203 Women (69.5%)	109 Women (64.9%)
	89 Men (30.5%)	59 Men (35.1%)
Race/Ethnicity:	144 Non-Hispanic White (49.3%)	49 Non-Hispanic White (29.2%)
	100 Black/African American (34.2%)	13 Black/African American (7.7%)
	11 Asian (3.8%)	32 Asian (19.0%)
	18 Hispanic/Latino (6.2%)	36 Hispanic/Latino (21.4%)
	19 Other (6.5%)	38 Other (22.6%)
Family Income in Household of Origin:	18 Under $10,000 (6.2%)	7 Under $10,000 (4.2%)
	30 $10,000-$19,999 (10.3%)	8 $10,000-$19,999 (4.8%)
	29 $20,000-$29,999 (9.9%)	12 $20,000-$29,999 (7.1%)
	33 $30,000-$39,999 (11.3%)	16 $30,000-$39,999 (9.5%)
	37 $40,000-$49,999 (12.7%)	21 $40,000-$49,999 (12.5%)
	59 $50,000-$74,999 (20.2%)	57 $50,000-$74,999 (33.9%)
	40 $75,000-$99,999 (13.7%)	16 $75,000-$99,999 (9.5%)
	29 $100,000-$150,000 (9.9%)	18 $100,000-$150,000 (10.7%)
	17 Over $150,000 (5.8%)	13 Over $150,000 (7.7%)
Relationship to the Deceased	24 Immediate family (8.3%)	12 Immediate family (7.3%)
	175 Extended family (60.6%)	114 Extended family (69.1%)
	90 Friend (31.1%)	39 Friend (23.6%)
Cause of Death	129 Natural anticipated (44.2%)	76 Natural anticipated (45.2%)
	73 Natural sudden (25%)	47 Natural sudden (28%)
	48 Accident (16.4%)	26 Accident (15.5%)
	22 Suicide (7.5%)	10 Suicide (6.0%)
	16 Homicide (5.5%)	6 Homicide (3.6%)
	4 Other (1.4%)	3 Other (1.8%)

The ‘Southern sample’ was used for the EFA analyses, and the ‘Southwestern sample’ was used for the CFA analyses. Tests of concurrent and incremental validity were performed with each sample in separate but parallel analyses.

Development of the Unfinished Business in Bereavement Scale (UBBS)

The themes that emerged from two prior qualitative studies on unfinished business (one with bereaved college students and another with bereaved parents) were initially used to develop candidate UBBS items (Klingspon et al., 2015; Lichtenthal & Sweeney, 2013). These items were then reviewed and edited by two bereavement experts and authors on this paper (R.A.N. and W.G.L.), who were not directly involved in the initial creation of items. Based on their feedback, additional items were added to reflect common clinical concerns that relate to unfinished business.

In total, 47 candidate items were created and administered. Each item consisted of a declarative statement relating to unfinished business (e.g., I wish I had told _____ how much s/he meant to me). Participants were asked to rate the level of distress associated with each unfinished business item on a 5-point scale ranging from 1 = Not at All Distressed to 5 = Extremely Distressed.

Measures for Concurrent Validity Analyses

Inventory of Complicated Grief—Revised (ICG-R).

The Inventory of Complicated Grief–Revised (ICG-R) is a 30-item measure that assesses PGD symptoms (Prigerson & Jacobs, 2001). These symptoms include intense yearning, inability to carry on with life, a sense of meaninglessness, and intrusive thoughts about the deceased or loss experience (Prigerson, Vanderwerker, & Maciejewski, 2008). The ICG-R uses a 5-point response scale that ranges from 1 = Never to 5 = Always, with higher scores indicating more severe symptomology. Widely used in bereavement research, the ICG-R has good test-retest reliability (r = 0.92; Boelen et al., 2003) and high internal consistency (Cronbach’s α ≥ 0.90; Guldin et al, 2011; Holland, Neimeyer, Boelen & Prigerson, 2009; Klingspon et al, 2015). Convergent validity has also been established with other grief measures (Boelen et al., 2003; Guldin et al., 2011).

A score of 90 or above on the ICG-R has been shown to correctly classify bereaved individuals as meeting criteria for PGD (or not) 80% of the time (Boelen et al., 2003). For the present study, this cut-score on the ICG-R was used to classify participants into low and high PGD risk groups, which were in turn used to establish optimal cut-scores on the UBBS. Individuals deemed to be at risk for PGD made up 4.9% and 4.2% of the Southern and Southwestern samples, respectively.

Integration of Stressful Life Experiences Scale (ISLES).

The Integration of Stressful Life Experiences Scale (ISLES; Holland, Currier, Coleman, & Neimeyer, 2010) is a 16-item measure that assesses the degree to which participants have made meaning from a stressful life event. A 5-point scale from strongly agree (1) to strongly disagree (5) is used to respond to declarative statements, such as “I have made sense of this event” and “I have difficulty integrating this event into my understanding about the world.” In this study, participants responded to this measure regarding their loss, and items were scored so that higher values indicated more positive meaning made of the event. ISLES scores have been shown to have strong internal consistency in a bereaved sample (Cronbach’s α = 0.94), moderate test-retest reliability after a 3-month interval (r = .57), and concurrent validity with relevant mental health outcomes (Holland et al., 2010). In particular, higher scores on the ISLES (indicating greater meaning made of a stressful life event) have been found to be associated with less prolonged grief and psychiatric distress (Holland et al., 2010).

Experiences in Close Relationships Instrument–Relationship Structures Questionnaire (ECR-RS).

This scale is composed of nine declarative statements that assess adult attachment in relationships along two dimensions: attachment anxiety and attachment avoidance (Fraley, Heffernan, Vicary, & Brumbaugh, 2011). This short measure has exhibited good internal consistency on both subscales (Anxiety: α = .85; Avoidance: α = .88) and has been shown to predict intra- and interpersonal outcomes better than more global measures of attachment. For this study, the statements were modified to pertain to the deceased. Of the nine declarative statements, three address attachment anxiety (e.g., “I often worried that this person didn’t really care for me”) and six address attachment avoidance (e.g., “I preferred not to show this person how I felt deep down”). Respondents are asked to rate their agreement on a scale ranging from disagree strongly (1) to agree strongly (7). Higher scores indicated higher attachment anxiety or avoidance.

Quality of Relationship Inventory – Bereaved Version (QRI-B).

The Quality of Relationship Inventory is a 24-item scale that assesses the quality of important relationships (Pierce, Sarason, & Sarason, 1991). Although the measure was not originally intended to measure the quality of relationships in a bereavement context, a brief 13-item version of the scale has been shown to have strong psychometric properties in a bereaved sample who responded to these items regarding the deceased (Bottomley, Smigelsky, Floyd, & Neimeyer, 2017). Particularly, a 2-factor model was supported with subscales measuring Closeness (e.g., How significant was this relationship in your life?) and Conflict (e.g., How upset did this person sometimes make you feel?) in the relationship. Each subscale was found to possess strong internal consistency (Closeness: α = .95; Conflict: α = .88). Higher scores on the QRI-B indicate higher levels of Closeness and Conflict.

Plan of Analysis

Exploratory factor analysis (EFA) was performed using data from the Southern sample. This EFA was conducted using principal axis factoring with oblique rotation (i.e., direct oblimin), which allowed factors to correlate. The optimal number of factors was determined by the Minimum Average Partial test (MAP test; Velicer, 1976). The MAP test involves examining the relative amounts of systematic and unsystematic variance remaining in the correlations matrix for all items after extracting increasing numbers of factors and selecting the solution that minimizes the partial correlations among items once variability due to the factors is partialed out. This analysis was performed using SPSS syntax developed by O’Connor (2000). To arrive at factors with items that load strongly on one factor and have minimal cross-loading with others, only items with loadings ≥ .5 and cross-loadings ≤ .2 were retained. Items that did not meet these two criteria were excluded from the UBBS and all subsequent analyses.

Data from the Southwestern sample was used to perform a confirmatory factor analysis (CFA) that tested the model derived from the EFA. In this analysis, items were treated as ordered categorical (i.e., ordinal) variables, and parameters were estimated using a mean and variance adjusted weighted least squares procedure. Goodness of fit indices were used to evaluate the fit of this model.

These indices included the chi-square goodness-of-fit test, the root mean square error of approximation (RMSEA; Browne & Cudeck, 1993), and the comparative fit index (CFI: Bentler, 1990). The chi-square goodness-of-fit test assesses the discrepancy between the observed covariance matrix and the covariance matrix of the fitted model. With large samples, however, virtually any parsimonious model is rejected, and with a small sample, model misfit may be undetected. Therefore, the RMSEA and CFI were primarily used to evaluate the fit of the model. The RMSEA is an index of discrepancy between the model and the data per degree of freedom. An RMSEA value of ≥ .10 indicates poor model fit, values of .05 to .08 indicate reasonable fit, and values ≤ .05 are considered close approximate fit between the hypothesized model and the sample data (Brown & Cudeck, 1993). The CFI compares the covariances of the specified model with a null model (one with no relationships), and values of .90 or higher are considered desirable (Bentler, 1990; Hu & Bentler, 1999). MPlus was used to conduct the CFA.

Drawing upon data from both samples, Pearson correlations were used to examine concurrent validity between UBBS scores (and potential subscale scores) and related bereavement outcomes, including complicated grief, meaning made of the loss, attachment security (specific to the deceased), and relationship quality with the deceased. Cronbach’s alpha was also calculated for the UBBS and any identified subscales. Incremental validity analyses were performed using hierarchical linear regression to determine the extent to which UBBS scores account for unique variance in PGD severity, above and beyond related constructs and any potential confounds (i.e., demographic/background factors that are found to be consistently correlated with UBBS scores). Finally, Receiver Operating Characteristics (ROC) analyses were used to establish cut-points on the UBBS (and any identified subscales) that can correctly identify those at risk for PGD (i.e., ICG-R score > 90) with at least 70% sensitivity—a true positive classification rate that is consistent with other successful mental health screening instruments (Martin, Potter, Crocker, Wells, & Colman, 2016).

Results

Exploratory Factor Analysis with Southern Sample

The MAP test performed with the Southern sample indicated that a 2-factor model provided the best fit. A 2-factor EFA resulted in 16 items that had high loadings (> .5) and low cross-loadings (< .2) for the first factor and 12 items (that adhered to the same criteria) for the second factor. Nineteen items were removed because they had low overall loadings (≤ .5 on both factors) and/or high cross-loadings (≥ .2 on both factors).

The items for the first 16-item factor pertained to a missed opportunity with the deceased or some aspect of the relationship that was believed to be incomplete (e.g., I wish we did more things together) and was labeled Unfulfilled Wishes. The second 12-item factor included items relating to an unresolved interpersonal problem with the deceased (e.g., I never got to resolve a breach in our relationship) or intrapsychic conflict prompted by his or her death (e.g., I feel that I need _______’s permission to live fully since s/he died); it was therefore labeled Unresolved Conflict. These items and their factor loadings are presented in Table 2.

Table 2.

Factor Loadings for Exploratory and Confirmatory Factor Analyses

Unfinished Business in Bereavement Scale (UBBS) Items	EFA with Southern Sample (n = 292)		CFA with Southwestern Sample (n = 168)
	Factor 1 Unfulfilled Wishes	Factor 2 Unresolved Conflict	Factor 1 Unfulfilled Wishes	Factor 2 Unresolved Conflict
I wish we did more things together.	.99	−.15	.93	--
I should have told him/her ‘I love you’ more often.	.96	−.12	.92	--
I didn’t get to say I love you one last time.	.91	−.15	.90	--
I wish I had told _________ how much s/he meant to me.	.87	−.06	.96	--
I wish I would have taken my chance to say goodbye.	.84	−.12	.92	--
Thinking about how _________ won’t be involved in my future is difficult for me.	.83	.03	.90	--
We didn’t spend enough time together	.79	−.02	.92	--
I never got the chance to say goodbye	.79	−.05	.90	--
I wish I would have told _________ how much I value the lessons that s/he taught me.	.79	.06	.91	--
I wish I could have given _________ one last special experience.	.79	.07	.94	--
I have trouble comprehending that _________ won’t be there for significant events in my future.	.77	.05	.90	--
I wish we were able to experience all life would have had in store together.	.73	.10	.94	--
I have special memories of _________ that I should have shared with him/her.	.68	.14	.91	--
I should have been there when _________ died.	.66	.07	.90	--
I wish I would have attended to _________’s needs more closely in his/her final days.	.65	.11	.91	--
I wish I had got to know him/her better	.61	.15	.80	--
I feel a deep sense of anger toward _________ that I don’t know how to resolve now that s/he is gone.	−.14	.94	--	.85
There were secrets in our relationship that should have been discussed.	−.12	.90	--	.89
I never got closure on some important issue or conflict in our relationship.	−.05	.86	--	.94
_________ kept something from me that I wish we could’ve discussed.	−.01	.86	--	.93
I held onto a secret that I wish I had told _________.	−.08	.85	--	.91
Because of the hurt/conflict in our relationship, I cut off _________ before s/he died.	−.08	.83	--	.91
I feel that I need _________’s permission to live fully since s/he died.	.02	.81	--	.94
I worry that I did something that contributed to _________’s death.	.00	.81	--	.85
I wish I had the chance to tell _________ that I forgive him/her.	.01	.79	--	.92
I never got to resolve a breach in our relationship.	.05	.79	--	.92
I wish we would’ve talked about his/her death more explicitly	.09	.74	--	.84
My relationship with _________ was deeply disappointing and now will never be resolved.	.05	.72	--	.77

Confirmatory Factor Analysis with Southwestern Sample

We next aimed to confirm this model in the Southwestern sample. Consistent with the exploratory model arrived at in the Southern sample, we tested a model with two latent factors—one of which represented an Unfulfilled Wishes factor (measured with the best 16 items established in the exploratory analyses) and another that represented an Unresolved Conflict factor (measured with the 12 best items established previously). This model was found to fit the data well, χ²(349) = 474.50, p < .001; CFI = .99; RMSEA = .046, 90% C.I. = .035-.056. The two factors were significantly correlated with one another (r = .90, p < .001), and all factor loadings were significantly greater than zero with p’s < .001 (see Table 2).

Relation Between Demographic/Background Variables and Unfinished Business

All 28 UBBS items were averaged to create a total score that could be used for mean comparisons and to examine correlations with salient demographic and background variables. Across both samples, participant age was not found to be significantly related to UBBS scores. In the Southern sample, no gender differences were observed. However, women were somewhat more likely to report unfinished business than men (M = 1.88 vs. M = 1.56) in the Southwestern sample, t(139) = 2.01, p = .05.

In the Southern sample, no relation was found between ethnic/racial background and UBBS total scores, F(4, 287) = 1.93, p = .11. However, in the Southwestern sample, African Americans were somewhat more likely to report being distressed by unfinished business (M = 2.62) compared to non-Hispanic white (M = 1.53) and multi-racial/ethnic (M = 1.64) individuals, F(5, 162) = 2.74, p = .02. Lower family income was associated with greater unfinished business distress in both the Southern (r = −.12, p = .04) and Southwestern (r = −.33, p < .001) samples.

The loss of immediate family members (as compared to friends or extended family) was more likely to elicit unfinished business in both the Southern (F(2, 286) = 7.22, p = .001) and Southwestern (F(2, 162) = 11.88, p < .001) samples. Across both samples, UBBS total scores did not significantly differ as a function of cause of death.

However, in unplanned subsidiary analyses, some differences related to cause of death were observed for the UBBS subscales, which were calculated by averaging items that loaded highly on each factor (see Appendix for items and scoring instructions). Specifically, those who had experienced a loss by violent means trended toward reporting more Unresolved Conflict than those who lost someone to natural causes in both the Southern (t(122) = 1.70, p = .09) and Southwestern (t(58) = 1.77, p = .08) samples. Loss by violent means, however, did not appear to confer similar risk on the Unfulfilled Wishes subscale (with p’s ranging from .44 - .94).

Internal Consistency and Concurrent Validity Analyses

The Unfulfilled Wishes and Unresolved Conflict subscales were found to be highly correlated with one another in both the Southern (r = .66, p < .001) and Southwestern (r = .77, p< .001) samples. These correlations between Unfulfilled Wishes and Unresolved Conflict scores were somewhat lower than that found in the CFA due to increased measurement error in the UBBS subscale scores, which were creating by averaging items (as opposed to calculating factor scores). In both samples internal consistency was found to be strong for items contributing to the total UBBS (α = .97 to .98), the Unfulfilled Wishes subscale (α = .97 to .98) and the Unresolved Conflict subscale (α = .94 to .96).

Correlations between the variables used for the concurrent validity analyses and UBBS total and subscale scores are presented in Table 3. Consistent with our hypotheses, these analyses indicated that more severe unfinished business (as assessed by UBBS total scores) was associated with more severe grief reactions, less meaning made of the loss, and a relationship with the deceased characterized by a high degree of closeness, conflict, and attachment anxiety coupled with low attachment avoidance.

Table 3.

Bivariate Correlations Between Unfinished Business and Other Measures

	Southern Sample (n = 292)			Southwestern Sample (n = 168)
	Unfulfilled Wishes Subscale	Unresolved Conflict Subscale	UBBS Total	Unfulfilled Wishes Subscale	Unresolved Conflict Subscale	UBBS Total
Mean	1.93	1.41	1.71	1.77	1.30	1.57
Standard Deviation	1.02	0.73	0.82	1.06	0.65	0.84
ICG-R	.65**	.59**	.68**	.71**	.69**	.74**
ISLES	−.26**	−.30**	−.29**	−.38**	−.43**	−.41**
ECR-Anxiety	.17*	.33**	.24**	.37**	.50**	.43**
ECR-Avoidance	−.25**	−.14*	−.23**	−.33**	−.22*	−.31**
QRI-Closeness	.42**	.16*	.36**	.43**	.26*	.39**
QRI-Conflict	.29**	.50**	.39**	.33**	.54**	.42**

Note:

^**= p < .001,

^*= p < .01;

ICG-R = Inventory of Complicated Grief Revised, ISLES = Integration of Stressful Life Experiences Scale, ECR = Experiences in Close Relationships, QRI = Quality in Relationships Inventory.

Unfulfilled Wishes were most strongly associated with low attachment avoidance and high closeness with the deceased. In contrast, those with high scores on the Unresolved Conflict subscale were most likely to report having a relationship with the deceased that was characterized by high levels of attachment anxiety and relational conflict.

Incremental Validity Analyses

Incremental validity was tested by running a set of hierarchical linear regression analyses (in both samples) with PGD symptoms as the dependent variables. For these analyses, all measures used in the concurrent validity analyses (excluding PGD symptoms) were included as independent variables in the first step of the model. Because they were found to be consistently related to UBBS scores, family income and relationship to the deceased (coded as 1 = immediate family member, 0 = other) were also entered as control variables in the first step.

Total UBBS scores were then entered in the second step of the model. As shown in Table 4, even after accounting for all the variables included in the first step of the model, UBBS scores accounted for 18% and 10% of unique variance in PGD severity in the Southern and Southwestern samples, respectively. These changes in R squared were statistically significant in both the Southern (ΔR² = .18, ΔF(1, 269) = 99.76, p < .001) and Southwestern (ΔR² = .10, ΔF(1, 155) = 51.27, p < .001) samples.

Table 4.

Incremental Validity Analyses with Prolonged Grief Severity as the Outcome

	Southern Sample (n = 292)				Southwestern Sample (n = 168)
	B	SE B	β	R2	B	SE B	β	R2
Model 1				.35***				.58***
Family Income	−0.58	0.43	−.07		−1.56	0.57	−.15***
Relationship to Deceased	7.81	3.72	.11*		16.26	4.77	.20**
Meaning Made of Loss	−0.42	0.07	−.33***		−0.40	0.07	−.32***
Attachment Anxiety	0.50	0.28	.10		1.12	0.29	.24***
Attachment Avoidance	−0.39	0.15	−.16*		−0.24	0.18	−.10
Closeness to Deceased	3.36	1.32	.17*		6.64	1.65	.31***
Conflict with Deceased	4.23	1.73	.15*		0.69	2.23	0.02
Model 2				.53***				.67***
Family Income	−0.30	0.37	−.04		−0.69	0.51	−.07
Relationship to Deceased	5.84	3.19	.08		10.94	4.22	.13*
Meaning Made of Loss	−0.28	0.06	−.22***		−0.27	0.06	−.22***
Attachment Anxiety	0.21	0.25	.04		0.55	.26	.12*
Attachment Avoidance	−0.34	0.13	−.14**		−0.19	.16	−.08
Closeness to Deceased	0.51	1.17	.03		4.06	1.48	.19**
Conflict with Deceased	0.84	1.52	.03		−0.50	1.95	−.02
Unfinished Business	11.94	1.20	.51***		11.29	1.58	.45***

^*p < .05,

^**p < .01,

^***p < .001

Notably, unfinished business (assessed via the UBBS) and meaning made of loss (assessed via the ISLES) emerged as the two independent variables that were most strongly and consistently associated with PGD severity. In a separate set of regression analyses, just these two independent variables were found to account for 50.2% to 60.2% of the variance in PGD severity in the Southern and Southwestern samples, respectively.

Establishing Optimal Cut-Scores for the Unfinished Business in Bereavement Scale

Using ROC analyses in both samples, cut scores ranging from 3.7 to 4.1 (median = 3.9) for the UBBS total were found to correctly classify 70% or more of individuals deemed at high risk for PGD (Sensitivity > .7) with minimal false-positives (i.e., incorrectly classifying low PGD risk individuals as being at high risk), occurring in less than 2% of cases (Specificity > .98).

A somewhat higher threshold was identified for Unfulfilled Wishes subscale scores to achieve similar levels of sensitivity and specificity. Across both samples, cut-scores ranging from 4.6 to 5.0 (median = 4.8) were found to optimally classify participants according to PGD risk. In contrast, a lower threshold was found to be optimal for Unresolved Conflict subscale scores with cut-scores ranging from 3.0 to 3.7 (median = 3.4).

Taken together, these analyses indicate that unfinished business starts to become problematic when people are at least “moderately distressed” by it. However, a stricter standard may need to be applied for experiences of Unfulfilled Wishes, which were only useful as an indicator of high PGD risk when participants reported being “extremely distressed” by them. For screening purposes, we recommend using median cut-scores to identify individuals with problematic unfinished business.

Development of a Brief Unfinished Business in Bereavement Scale

Because there is often a need for assessment tools that can be completed quickly, a brief version of the UBBS was created. Four items were chosen for each subscale, and items were selected that showed high factor loadings in the EFA and CFA and represented the full range of items in the scale. Based on these criteria, items 1, 3, 5, and 7 were chosen to represent Unfulfilled Wishes, and items 2, 4, 6, and 8 were selected for Unresolved Conflict. The average of these eight items can be used to compute a total UBBS-Brief score (see Appendix).

Across both samples, extremely high correlations were found between UBBS-Brief total/subscale scores and the full versions of the corresponding scales (with r’s ranging from .95 to .98). An identical pattern of results was also obtained when concurrent and incremental validity analyses were replicated using the UBBS-Brief. Though still well within the acceptable range, internal consistency was somewhat lower for the brief versions of the total UBBS (α = .90 to .92), the Unfulfilled Wishes subscale (α = .91 to .94), and the Unresolved Conflict subscale (α = .86 to .88) compared to the full versions.

Discussion

The results of this study suggest that the UBBS is a psychometrically valid and reliable instrument for assessing unfinished business in bereavement that is comprised of two related factors. The first, Unfulfilled Wishes, was characterized by perceptions of missed opportunity with the deceased and/or the belief that some final parting words (generally of a positive nature) were left unspoken. The second factor, Unresolved Conflict, gauged the extent to which an argument, indiscretion, or secret was never fully addressed when the deceased was alive. It also captured inner conflict prompted by the death (e.g., not being able to live fully without the deceased’s permission). Notably, in a recent mixed methods study of unfinished business among advanced cancer patients, two similar overarching themes emerged—one related to issues that were viewed as “incomplete” and another that focused on problems, questions, or disputes that were “not resolved” (Masterson et al., in press). These parallel findings with different samples and methods lend support to the notion that unfinished business in an end-of-life context primarily occurs along these two dimensions.

Strong support was also found for the concurrent validity of the UBBS. Consistent with our hypotheses, unfinished business distress was found to be associated with more severe PGD symptoms, less meaning made of the loss, and greater attachment anxiety with the deceased. In addition, the loss of close relationships (particularly immediate family members) were more likely to elicit unfinished business. Perhaps due to this closeness, relationships that prompted unfinished business also tended to be characterized by less avoidance and greater conflict.

The Unfulfilled Wishes and Unresolved Conflict subscales of the UBBS generally adhered to a similar pattern in the concurrent validity analyses. However, some key differences emerged highlighting the importance of distinguishing between these two dimensions. In particular, Unfulfilled Wishes were most pronounced when the relationship with the deceased was close and characterized by low levels of avoidance. Thus, it appears that relationships that elicited concerns about missed opportunities or unspoken words of affirmation were generally positive and loving. The relationships most likely to give rise to Unresolved Conflict, on the other hand, were those characterized by conflict and relational anxiety when the deceased was still alive. Losses by violent means (i.e., accident, suicide, or homicide) were also found to be somewhat more likely to elicit Unresolved Conflict, which converges with the results of Holland, Plant, Klingspon, and Neimeyer (in press) using a simple one-item measure of unfinished business.

This pattern of findings paints a more severe and complex clinical picture of Unresolved Conflict, compared to Unfulfilled Wishes. Given the longstanding conflict and anxiety in the relationship with the deceased, coupled with the increased likelihood of there being a sudden and violent ending to it, it is perhaps unsurprising that even those who reported being only “moderately distressed” by Unresolved Conflict were still at heightened risk for PGD. In contrast, people reporting experiences of Unfulfilled Wishes only seemed to be at higher risk for the disorder when they were “extremely distressed” by them. Of course, bereaved individuals could be significantly troubled by either form of unfinished business, even if it is not associated with a formal PGD diagnosis.

Clinical Implications

The findings of this study support the theoretical rationale behind interventions focusing on resolving unfinished business and finding meaning in the aftermath of loss, such as evocative empty-chair dialogues (Paivio & Greenberg, 1995; Jordan, 2012; Lichtenthal, Panjwani, & Masterson, in press; Neimeyer, 2012a) or letters written to the deceased (Neimeyer, 2012b). When themes of Unfulfilled Wishes are prominent, for example, clients might be asked to visualize the deceased in the empty chair opposite them and use first- and second-person “I-you” language to convey how they are feeling now in the relationship, and what they are left needing now. The therapist might then prompt clients toward greater depth and honesty through restatement and encouragement for elaboration, after which they might be asked to shift to the position of the deceased and respond as the loved ones would were they able to hear the clients’ expressions.

Conversely, when themes of Unresolved Conflict with a neglectful, abusive or oppressive partner, parent or other relationship predominate, therapists might facilitate an equally candid expression of client pain or grievance, but without affording the deceased (visualized in the empty chair) the opportunity to respond with predicted dismissal, minimization, or blaming (see Neimeyer, 2012a for procedural details). Similarly, when correspondence with the deceased is used, the therapist might optionally prompt clients with various “conversation starters” in the form of incomplete sentences suggested by the themes identified in the UBBS (e.g., “The one thing I most wanted to tell you was…”, “The question I most wanted to ask you was…”, “The words I most needed to hear from you were…) (c.f. Neimeyer, 2012b).

Incremental validity analyses in the present study revealed that unfinished business remained a unique indicator of PGD symptoms even after statistically controlling for the quality of the relationship with the deceased and other potential confounds. In addition, unfinished business and meaning made of the loss together accounted for 50-60% of the variance in PGD symptom severity. Thus, it seems that one’s specific subjective interpretations of the loss and ongoing relationship with the deceased are more relevant to their current state of grieving than more general retrospective appraisals of the relationship (e.g., as being close or conflictual).

In this respect, the UBBS (in either its full or brief form) could add useful detail to therapies guided by contemporary models of grief, such as the Two-Track Model of Bereavement (Rubin, Malkinson & Witztum, 2008), which focuses not only on bereaved people’s biopsychosocial functioning, but also on their previous and ongoing relationship to the deceased, as well as attachment-informed approaches to grief therapy (Kosminsky & Jordan, 2016) that work with specific relational disappointments that complicate post-loss adjustment. Likewise, the UBBS is well configured to contribute to a Meaning Reconstruction approach to grief therapy (Neimeyer, 2018). Structured intervention approaches, such as Meaning-Centered Grief Therapy, that are grounded in a Meaning Reconstruction approach and make use of letter-writing exercises and imaginal dialogues with the deceased have been used successfully to address concerns related to unfinished business (Lichtenthal, Napolitano, Roberts, Sweeney, & Slivjak, 2017; Lichtenthal, Panjwani, & Masterson, in press). With this approach’s emphasis on helping clients not only process the “event story” of the death itself, but also to access the “back story” of the relation to the deceased (Neimeyer, 2018), the UBBS may be used to help restore a sense of attachment security (as reflected in themes of Unfulfilled Wishes) and to address residual tensions (as captured in themes of Unresolved Conflict).

Whatever their theoretical orientation, given the empirical and clinical relevance of unfinished business, clinicians and researchers working with bereaved populations would be well-advised to include the UBBS as part of their assessment battery. Although the internal consistency was somewhat stronger for the full 28-item version of the scale, an abbreviated 8-item version was also created for screening purposes. The UBBS-Brief was highly correlated with the full scale, and all results were successfully replicated with this abbreviated version. Recommended cut-scores were also proposed for the UBBS and both subscales based on PGD risk. These benchmarks can be used in clinical or research settings to identify individuals with highly problematic levels of unfinished business.

Limitations and Future Directions

Notwithstanding the strength of these findings, further research with the UBBS is needed to address several yet unanswered questions about its psychometric properties. First, this study did not examine the performance of the UBBS over time, and its temporal stability remains unknown. It is also unclear the extent to which unfinished business distress, as assessed by the UBBS, is amenable to change in the context of a clinical treatment setting. Further research that implements a longitudinal design and/or uses the UBBS as a clinical outcome would help to address these gaps.

Although striking similarities were observed across the two samples of bereaved young adults, varying in terms of region of the U.S and ethnic/racial composition, more work still needs to be done to fully explore the generalizability of these findings. For example, those who grew up in homes with limited family income were found to report more unfinished business, suggesting that social and economic forces partly contribute to these experiences. However, more research on the UBBS is needed to fully understand how these broader factors come to bear on unfinished business. Such research would ideally include a sample that is more diverse with respect to nationality, age and life stage. Given that our sample was drawn from a less distressed population overall (compared to a sample of recently bereaved parents or spouses, for example), it will also be important to determine the extent to which these findings can be replicated in samples with more severe grief reactions.

Despite these remaining questions about the generalizability of the UBBS, in this study scores were not found to substantially differ according to age, gender, or ethnicity, indicating that the UBBS has relevance for a broad spectrum of social groups. Given its strong psychometric properties and clinical relevance, the UBBS represents a significant step forward in understanding and assessing experiences of unfinished business in bereavement.

Appendix: Unfinished Business in Bereavement Scale (UBBS)

Sometimes people who have lost a significant person in their life are left with the sense that something was unsaid, unfinished, or unresolved in the relationship when the person died. Below is a list of different kinds of “unfinished business” that you may or may not have experienced. For each statement, please indicate how distressed you have been about this issue in the past month. The blank spaces below represent the name of the deceased.

	How distressed have you been by this issue in the past month?>
	Not at all distressed	A little distressed	Neutral	Distressed a lot	Extremely Distressed
1. I wish we did more things together.	1	2	3	4	5
2. There were secrets in our relationship that should have been discussed.	1	2	3	4	5
3. I should have told him/her ‘I love you’ more often.	1	2	3	4	5
4. I never got closure on some important issue or conflict in our relationship.	1	2	3	4	5
5. I wish I had told _______ how much s/he meant to me.	1	2	3	4	5
6. I feel that I need _______’s permission to live fully since s/he died.	1	2	3	4	5
7. I wish I would have taken my chance to say goodbye.	1	2	3	4	5
8. I feel a deep sense of anger toward_______ that I don’t know how to resolve now that s/he is gone.	1	2	3	4	5
9. I wish I would have attended to _______’s needs more closely in his/her final days.	1	2	3	4	5
10. _______ kept something from me that I wish we could’ve discussed.	1	2	3	4	5
11. I didn’t get to say I love you one last time.	1	2	3	4	5
12. I held onto a secret that I wish I had told _______.	1	2	3	4	5
13. We didn’t spend enough time together.	1	2	3	4	5
14. Because of the hurt/conflict in our relationship, I cut off _______ before s/he died.	1	2	3	4	5
15. I should have been there when ________died.	1	2	3	4	5
16. I worry that I did something that contributed to _______’s death.	1	2	3	4	5
17. I wish I would have told _______ how much I value the lessons that s/he taught me.	1	2	3	4	5
18. I wish I had the chance to tell _______ that I forgive him/her.	1	2	3	4	5
19. Thinking about how _______ won’t be involved in my future is difficult for me.	1	2	3	4	5
20. I never got to resolve a breach in our relationship.	1	2	3	4	5
21. I wish I had got to know him/her better.	1	2	3	4	5
22. My relationship with _______ was deeply disappointing and now will never be resolved.	1	2	3	4	5
23. I have special memories of _______ that I should have shared with him/her.	1	2	3	4	5
24. I wish we would’ve talked about his/her death more explicitly.	1	2	3	4	5
25. I have trouble comprehending that _________ won’t be there for significant events in my future.	1	2	3	4	5
26. I wish I could have given _______ one last special experience.	1	2	3	4	5
27. I never got the chance to say goodbye.	1	2	3	4	5
28. I wish we were able to experience all life would have had in store together.	1	2	3	4	5

Scoring: To calculate a total UBBS score, average scores for all 28 items. The Unfulfilled Wishes subscale can be calculated by averaging items 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, 21, 23, 25, 26, 27, and 28. The Unresolved Conflict subscale can be calculated by averaging items 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24. The first eight items of the scale can be used for the Brief UBBS, with items 1, 3, 5, and 7 tapping into Unfulfilled Wishes and items 2, 4, 6, and 8 tapping into Unresolved Conflict. Average scores ≥ 3.9, 4.8, and 3.4 on the UBBS total, Unfulfilled Wishes subscale, and Unresolved Conflict subscale, respectively, are indicative of problematic unfinished business.