Measuring Grief in the Context of Traumatic Loss: A Systematic Review of Assessment Instruments

Abstract

Following traumatic loss, defined as the death of a loved one due to unexpected or violent circumstances, adults may experience a myriad of grief-related problems. Given the addition of Prolonged Grief Disorders into the Diagnostic and Statistical Manual for Mental Disorders Fifth Edition, Text-Revision and influx of unexpected deaths due to the global Coronavirus pandemic, there is heightened interest in the measurement of grief-related processes. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify measures of grief used in studies of adults who experienced traumatic loss. Searches yielded 164 studies that used 31 unique measures of grief-related constructs. The most commonly used instrument was the Inventory of Complicated Grief-Revised. Half of the measures assessed constructs beyond diagnosable pathological grief responses. Given the wide variation and adaptations of measures reviewed, we recommend greater testing and uniformity of measurement across the field. Future research is needed to adapt and/or design measures to evaluate new criteria for Prolonged Grief Disorder.

Traumatic loss has been conceptualized as the death of a significant person that occurs without warning, involves violence or damage to the decedent’s body, is perceived as being preventable, and/or is directly witnessed by the survivor (Barlé et al., 2017). For this paper, a loss is considered traumatic when a significant death was due to sudden and/or violent causes (e.g., suicide, accident, homicide, drug-related overdose, natural disaster, war- or terror-related conflict, heart attack, and perinatal). Epidemiological studies demonstrate that approximately half of American adults will experience at least one unexpected (or violent) death of a close other in their lifetime (e.g., Keyes et al., 2014). Given challenges arising from the COVID-19 pandemic and the current Opioid crisis causing an exorbitant rise in deaths, experts predict unexpected death to increase (Eisma et al., 2021; Mattson et al., 2021). Traumatic loss yields a more protracted and challenging process of grief, with greater levels of impairment compared to expected or developmentally normative losses (*Kristensen et al., 2012). Traumatic loss is also associated with elevated rates of psychiatric morbidity, such as posttraumatic stress disorder (PTSD), depression, anxiety, and pathological forms of grief, such as prolonged grief disorder (PGD), that will be included in the forthcoming text revision of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5-R; Boelen & Lenferink, 2019; *Kristensen et al., 2012).

A recent systematic review (Treml et al., 2020) identified 11 instruments and highlighted the magnitude of assessment instruments used to assess the grief process, specifically for PGD and other proposed diagnoses of pathological grieving such as Complicated Grief (CG) and Persistent Complex Bereavement Disorder (PCBD). However, the systematic review was broad in scope and did not examine instruments specific to traumatic loss. To our knowledge, there has been no systematic review of instruments to assess grief (e.g., pathological symptoms, grief-related constructs, and normative reactions) in the context of traumatic loss. This review aims to identify and describe the variation of measures employed in traumatic grief research to assist future research and clinical care with this vulnerable, yet understudied, population Table 1.

Table 1.

Overview of Instruments Assessing Grief in the Context of Traumatic Loss.

Instrument	Reference	Construct Assessed/Diagnostic Capacity	Versions Available/Other Names for Measure)	Format, Number of Items, Scales/Factors	Scoring/Interpretation	Language(s)	#Of Studies
Measures of Pathological Grief Symptoms
Inventory of Complicated Grief	Prigerson et al. (1995)	Complicated Grief, Prolonged Grief symptoms Cut off scores provided for probable dx of CG, PCBD, PGD	ICG-Revised, Inventory of Traumatic Grief, Traumatic Grief Evaluation of Response to Loss; Prolonged Grief Disorders Interview, Prolonged Grief Disorders Scale	Self-report and clinician interview formats available; 19 items; Findings vary with respect to factor structure	Higher scores indicate greater CG/PGD symptom severity. A score of 25 or greater indicates probable CG diagnosis.	English, Dutch, Hebrew, Albanian, Chinese, Korean, German, Norwegian, Italian, Arabic, Khmer, Turkish	69
Prolonged Grief Disorder-13	Prigerson & Maciejewski (2008)	Prolonged Grief Disorder symptoms Cut off scores provided for probable dx of PGD	NA	Self-report; 13 items corresponding with diagnostic criteria for PGD	Algorithm to determine presence of Prolonged Grief Disorder diagnosis	English, Chinese, Tiv, French, Kiryarwanda	13
Traumatic Grief Inventory-Self Report	Boelen & Smid (2017)	PCBD and PGD Symptoms PCBD and PGD Diagnoses	Many items taken from the ICG; 10-item version also used	Self-report; 18 items; One factor	PCBD score: sum items 1–11 and 13–18. PGD score: sumitems 3–13. Higher scores indicate greater severity.	English, Chinese, Arabic, Dutch	12
Complicated Grief Assessment-Self-Report	Prigerson & MaCiejewski (2006)	PGD Symptoms PGD diagnostic screen	NA	Self-report; 9 items consistent with PGD diagnostic criteria.	Higher scores indicate greater severity; Diagnostic criteria can be applied to identify a provisional diagnosis of PGD.	English, Khmer	6
Texas Inventory of Grief	Faschingbauer et al. (1977)	Grief intensity No diagnostic capacity	Texas Revised Inventory of Grief (21 items); Expanded Texas Inventory of Grief (58 items)	Self-report; 14 items; Two Factors: (1) Past Behaviors (TRIG I), (2) Present Feelings (TRIG II)	Higher scores on the Present Feelings scale represent unresolved grief	English	5
Structured Clinical Interview for Complicated Grief	Bui et al. (2015)	Complicated Grief, PCBD, PGD Cut off scores provided for probable dx of CG, PCBD, and PGD	NA	Clinician-administered interview; 31 items; Five Factors: (1) Yearning and Emotional Pain, (2) Difficulty Accepting the Death, (3) Emotional Numbness, Loneliness, and Social Disconnection, (4) Suicidal Ideation and Meaninglessness, (5) Avoidance and Negative Effects	Higher scores indicate greater severity.	English, Korean	2
International ICD-11 Prolonged Grief Disorders Scale	Killikelly et al. (2020)	Symptoms of PGD as outlined in ICD-11 PGD Diagnosis	NA	Self-report; 34 items; Two Factors: (1) Core Grief, (2) Culturally-Specific Symptoms	Higher scores indicate greater severity.	German, Chinese	2
Revised Grief Experiences Inventory	Lev et al. (1993)	Broad grief experiences No diagnostic capacity	Shortened version of Grief Experiences Inventory (Sanders, Mauger, & Strong, 1985)	Self-report; 22 items; Four Factors: (1) Existential Concerns, (2) Depression, (3) Tension and Guilt, (4) Physical Distress	Higher scores within each of the domains reflect greater challenges of each grief-related theme.	English	2
Hogan Grief Reactions Checklist	Hogan & Schmidt (2001)	Grief reactions No diagnostic capacity	NA	Self-report; 61 items; Six Factors: 1) Despair, 2) Panic Behavior, 3) Personal Growth, 4) Blame and Anger, 5) Detachment, 6) disorganization	Higher scores indicate greater severity.	English	2
UCLA Grief Inventory	Layne et al. (2006)	Grief reactions No diagnostic capacity	Expanded Grief Inventory (28 items; Layne et al., 2001)	Self-report; 20 items; Three Factors: (1) Normal Grief, (2) Traumatic Grief, (3) Existentially Complicated Grief	Higher scores indicate greater severity; higher scores on each scale indicate greater difficulties with that grief theme.	Bosnian, English	1
Brief Grief Questionnaire (BGQ)	Ito et al. (2012)	Screener for CG	NA	Self-report or clinician interview; 5 items; Factor structure NR	Score of ≥ 4 indicates positive screen for probable CG	English	1
Clinical Global Impressions Scale-Severity	Shear et al. (2005)	Severity of CG No diagnostic capacity	NA	Clinician Ratings; unknown items; Factor Structure N/A	Higher scores indicate greater severity.	English	1
Modified Version of the Complicated Grief Module	Horowitz et al. (2003);Langner & Maercker (2005)	PGD Symptoms PGD Diagnosis	NA	Clinician-administered interview; 34 items; Three Factors: (1) Intrusions, (2) Avoidance, 3) Failure to Adapt to Loss	Higher scores indicate greater severity; Diagnostic criteria can be applied to identify a provisional diagnosis of PGD.	German, English	1
Persistent Complex Bereavement Inventory Core Grief Subscale	Lee (2015)	Persistent Complex Bereavement Disorder symptoms Cut off scores provided for probable dx of PCBD	NA	Self-report; 16 items; Three Factors: 1) Core Grief, 2) Reactive Distress, 3) Social/ Identity Disruption	Higher scores indicate greater symptom severity.	English	1
Measures of Grief-Related Constructs
Grief Experiences Questionnaire	Barrett & Scott (1989)	Grief severity; grief themes prevalent among suicide loss No diagnostic capacity	16-Item version (Feigelman & Cerel, 2020)	Self-report; 55 items; Eight Factors: (1) Somatic Reactions, (2) Search for Explanation, (3) Loss of Social Support, (4) Stigmatization, (5) Guilt, (6) Responsibility, (7) Shame, (8) Rejection	Total summed score reflects grief severity; Scale scores reflect respective grief theme	German, English, Dutch, Flemish	12
Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ)	Boelen & Van den Bout (2010)	Avoidance in cognitive-behavioral model of CG/PGD Avoidance clusters in CB and PGD diagnoses	NA	Self-report; 9-items. Two Factors: (1) Depressive Avoidance, (2) Anxious Avoidance	Higher scores indicate greater severity of avoidance behavior.	English and Dutch	5
Grief Cognitions Questionnaire	Boelen & Lensvelt-Mulders, (2005)	Negative loss-related cognitions No diagnostic capacity	NA	Self-report; 38 items; Nine Factors: 1) Self, 2) Life, 3) World, 4) Future, 5) Selfblame, 6) Others, 7) Catastrophic Misinterpretations, 8) Cherish Grief, 9) Appropriateness of Grief.	Higher summed scores indicate greater frequency of negative cognitions and their subtypes.	English, Dutch, Turkish	4
Death Imagery Scale	Rynearson & Correa (2008)	Grief-related imagery No diagnostic capacity	Dying-Imagery Scale Revised (DIS-R; 15 items)	Self-report; 5 items; Three Factors: (1) Reenactment, (2) Remorse, (3) Revenge	Higher scores indicate more frequent death imagery.	English	3
Utrecht Grief Rumination Scale	Eisma et al. (2014)	Grief-specific rumination No diagnostic capacity	NA	Self-report; 15 items; Five Factors: (1) Reactions, (2) Injustice, (3) Counterfactuals, 4) Meaning, (5) Reactions of Others	Higher total scores indicate greater grief-related rumination; summed scale scores reflect severity of grief rumination subtypes	English, Chinese, Dutch	1
Measures Developed for Specific Types of Loss
Perinatal Grief Scale	Toedter et al. (1988)	Perinatal grief No diagnostic capacity	Munich Grief Scale; Perinatal Grief Scale-Shortened	Self-report; 104 items (33 items for short version); Three Scales: 1) Active Grief, 2) Difficulty Coping, and 3) Despair	Higher scores indicate greater severity.	German, Swedish, French, Sinhala, Chinese, English, Arabic, Indian	31
Perinatal Grief Intensity Scale	*Hutti et al. (1998)	Perinatal grief No diagnostic capacity	NA	Self-report; 14 items; Three Factors: (1) Reality, (2) Confront Others, (3) Congruence	Suggested cut off score of 3.53 (Hutti et al., 2017) to identify those in need of follow-up. Mean score for each subscale can be derived from averaging subscale item scores	English	4
Pandemic Grief Scale	*Lee & Neimeyer, (2020)	Grief related to loss from COVID-19 No diagnostic capacity	NA	Self-report; 5 items; Onefactor	Higher scores indicate greater severity.	English, Turkish	3
Perinatal Bereavement Grief Scale	Ritsher & Neugebauer (2002)	Longing and yearning for the pregnancy and baby No diagnostic capacity	NA	Self-report; 16 items; One factor	Higher scores indicate greater severity.	English, Spanish	2
Measures of Normative Grief Reactions
Core Bereavement Items	Burnett et al. (1997)	Bereavement phenomena No diagnostic capacity	NA	Self-report; 17 items; Three Factors: (1) Images and Thoughts, (2) Acute Separation, (3) Grief	Higher scores on each of the factors indicate greater severity on that dimension of bereavement.	English	1
Two-Track Bereavement Questionnaire	Rubin et al. (2009)	Bereavement experiences consistent with Two-Track Model of Bereavement (TTMoB) No diagnostic capacity	NA	Self-report; 70 items; Five Factors: (1) General Biopsychosocial Functioning, (2) Traumatic Perception of the Loss, (3) Active Relational Grieving, (4) Close and Positive Relationship, (5) Conflictual Relationship	Higher scores on each factor indicate greater severity or agreement of each of the facets of the TTMoB.	English	1

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations (Moher et al., 2009) in PUBMED, PsycINFO, and OVID. We restricted searches to peer-reviewed published work in English between January 1998 and March 2021, to capture measures of grief currently used in the literature. We used the following keywords in each search: (assessment tool OR measurement tool OR measurement scale OR psychometrics OR instrument OR questionnaire OR self-report OR structured interview) AND (grief or complicated grief OR prolonged grief OR complex grief OR traumatic grief OR bereavement OR complicated grief OR complex bereavement). Reference lists from relevant papers were reviewed for potentially eligible studies. Studies were included if: a measure of grief was used and the sample or a subsample was exclusively adults (18 years or older) bereaved by a traumatic death. Studies were excluded if the sample or subsample did not include adults bereaved by traumatic death and/or a measure of grief was not used. Of note, the study team is conducting a parallel review paper of measures of grief used in child samples. Two authors screened each article and a third author reviewed disagreements, which were minimal.

Two authors (N.E., J. B.) independently extracted data from each study on: grief measure(s) used; sample size and demographics; time since death; cause of death; whether the measure was used as a treatment outcome; and time intervals if the measure was repeated. Psychometric data of the grief measures were extracted if available, otherwise data was extracted from the measures’ development and initial validation.

Results

A total of 164 studies were included for review (See Appendix A PRISMA Flow Diagram).¹ Studies were considered as unique research questions and we note all cases where multiple studies used the same sample. Across studies, 31 measures of grief were used (See Appendix B Supplementary Table 1), many were adaptations of other measures and six were study specific (not included in tabular data).

Measures of Pathological Grief Symptoms

The Inventory of Complicated Grief (ICG; H. Prigerson et al., 1995) was the most widely used measure in the studies reviewed. Including all adapted versions, the ICG was used in 68 studies, 59 of which were unique samples. The ICG assesses the distinct cluster of symptoms inherent in pathological grief (e.g., anger, disbelief, and grief-related perceptual disturbances) that are distinguishable from mood and anxiety-related disorders. The ICG consists of 19 self-report items using a 5-point Likert-type scale from Never to Always. The ICG has been applied to many kinship categories and loss types and is the most widely used instrument for assessing symptoms of pathological grief (e.g., CG, now ref/erred to as PGD). Given the ICG’s ubiquity in research and practice over the past two decades, numerous versions and adaptations were included in the review (e.g., *Barnes et al., 2012; Feigelman & Cerel, 2020). For example, the ICG-R (H. G. Prigerson & Jacobs, 2001) also referred to as the Inventory of Traumatic Grief (ITG; Saindon et al., 2014) when employed in a structured clinical interview format, is an expanded 17-item version of the ICG. The ICG has been employed as a diagnostic interview or rater-based assessment, such as the Prolonged Grief Disorder Interview (PGD-I; H. G. Prigerson et al., 2009) found in three studies (Morina, 2011; Morina & Emmelkamp, 2012; Morina et al., 2011). The Prolonged Grief Disorder Scale (*Boelen et al., 2012), found in three studies (Boelen, 2015; *Boelen & Lenferink, 2020; Eisma et al., 2020), is another ICG iteration that consists of all proposed PCBD DSM-5 criteria. Other instruments were derived from the ICG but are considered distinct measures (e.g., PG-13, TGI-SR, CGA-SR; described separately below). The ICG provides an overall symptom severity score, with scores above 25 suggesting significant impairment in numerous psychosocial domains, and indicative of a probable CG diagnosis. Overall, the ICG evidenced strong psychometric properties with reliability coefficients generally above .90. The ICG-R yields a composite score reflecting symptom severity and a dichotomous diagnosis for PCBD in DSM-5. Reliability coefficients for both the ICG-R and Prolonged Grief Disorder Scale were strong among studies in this review, ranging from .80 to .97.

The Prolonged Grief Disorder-13 (PG-13; H. G. Prigerson et al., 2009) was used in 15 studies (*Bartik et al., 2013; *Captari et al., 2020; *Chukwuorji et al., 2018; Goldstein et al., 2019; *Hardt et al., 2020; *Hinton et al., 2013; Matthews et al., 2019; Milman et al., 2018, 2019; Schaal et al., 2009; Tang et al., 2019; Williams et al., 2019; *Zhou et al., 2020), two of which used the same sample (Schaal et al., 2010, 2012). One of the studies modified the wording of items for parents who lost children to sudden infant death syndrome (Goldstein et al., 2019). The PG-13 is a 13-item diagnostic tool that assesses for the presence/absence of PGD symptoms. Respondents rate on a Likert-type scale (1=not at all to 5=several times a day/overwhelmingly) the frequency of symptoms consistent with PGD criteria. Respondents must endorse “at least once a day” or “quite a bit” on any item to be considered clinically elevated. Items 3 and 13 assesses symptom duration and functional impairment, respectively. Studies reported strong psychometrics for the PG-13 with internal consistency values ranging from .82 to .91.

The Traumatic Grief Inventory-Self Report (TGI-SR; Boelen & Smid, 2017), an 18-item measure, was used in 12 studies (*Boelen et al., 2018; Boelen et al., 2019; *Comtesse & Rosner, 2019; Djelantik et al., 2020; Eisma et al., 2021; Heus et al., 2017; *Lenferink et al., 2017, 2019, 2020a, 2020b; Lenferink et al., 2020; Tang & Xiang, 2021), five using the same sample of those bereaved by a plane crash (*Lenferink et al., 2017). The TGI-SR consists of all 16 proposed symptoms of PCBD, an additional symptom of PGD not included in a PCBD diagnosis (“feeling stunned/shocked”), and an item assessing functional impairment. Items are rated on a 5-point Likert scale from 1 (“never”) to 5 (“always”) and has two parts: inventory of lost loved ones and 18-item measure described above. Scores are computed into a provisional diagnosis of PCBD and/or PGD and/or severity of symptoms and symptom change over time (Boelen & Smid, 2017). Boelen et al. (2019) found one factor with strong internal consistency (α=.91 for all items, .90 for PCBD items, and .88 for PGD items), and convergent validity with other psychopathology measures.

The Complicated Grief Assessment Self-Report (CGA-SR; Prigerson & MaCiejewski, 2006) was used in six studies (*Barnes et al., 2012; Neria et al., 2007; Stammel et al., 2020), three of which used the same sample (Baddeley et al., 2015; Rheingold et al., 2015; Williams et al., 2018). The CGA-SR is a self-report measure that assesses symptoms of PGD, such as separation distress and associated impairment following bereavement. For a diagnosis of PGD, respondents must endorse one of two Criterion A, C, and D items, and at least four of eight Criterion B symptoms. Scores from Criterion B range from 9 to 45; higher scores indicate greater severity. The CGA-SR was developed based on the ICG and Cronbach alphas ranged from .82 to .84.

Texas Inventory of Grief (TIG, Faschingbauer et al., 1977), used in five studies that each used unique samples (*Abbott & Zakriski, 2014; *Kristensen et al., 2012; Lubens & Silver, 2019; Pfefferbaum et al., 2001; Wayment & Silver, 2021), was originally developed as a 14-item Likert-type scale to assess feelings and behaviors immediately following the death of a family member and the extent of unresolved grief. In this review, a 13-item measure based on the TIG was used in one study (Pfefferbaum et al., 2001). The Expanded Texas Inventory of Grief (ETIG; Zisook et al., 1982), a 58-item expansion of the original TIG that assesses both contemporaneous grief symptoms (Present Feelings=34 items) and reactions immediately following the death (Past Feelings = 24) was in one study (*Kristensen et al., 2012). The ETIG uses a 5-point scale ranging from completely false to completely true. The Texas Revised Inventory of Grief (TRIG; Faschingbauer et al., 1987) was used in one study (*Abbott & Zakriski, 2014). Consistent with the original TIG and ETIG, the TRIG assesses grief at time of assessment and death on a 5-point scale (1 = Completely true to 5 = Completely false), with a reduced form of 21 statements (e.g., “I found it hard to sleep after the person died”; “I can’t avoid thinking about the person who died”). Both the original developers and subsequent studies investigated the factor structure of the TRIG and identified two distinct factors, Past Behaviors (TRIG I) and Present Feelings (TRIG II). Psychometric properties were strong, with sound inter-item reliability for the TRIG I (α = .93) and TRIG II (α = .94), as well as across timepoints (α from .83 to .84).

The Structured Clinical Interview for Complicated Grief (Bui et al., 2015) was developed based on clinical and research observations of CG and used in two studies with unique samples (*Choi & Cho, 2020; Mauro et al., 2019). It is formatted similarly to the Structured Clinical Interview for DSM-IV, and evaluates proposed diagnostic criteria for PGD, CG, and PCBD. The measure has 31 items rated on a 3-point Likert scale (1 = “not present,” 2 = “unsure or equivocal,” 3=“Present”) evaluating past month severity. Scores range from 31 to 93 and can be calculated by summing items. Bui and colleagues found satisfactory internal consistency (α = .77), test-retest reliability (interclass correlation = .68), interrater reliability (interclass correlation=.95), and adequate convergent validity with the ICG (r = .57, p < .001) and with grief related-functional impairment (r = .47, p < .001).

The International ICD-11 Prolonged Grief Disorders Scale (IPGDS; *Killikelly et al., 2020), used in two studies (*Killikelly et al., 2020; Tang & Xiang, 2021), was developed using a “bottom-up approach” involving qualitative interviews and psychometric validation in German and Chinese samples (*Killikelly et al., 2020). Focus groups identified culturally specific grief symptoms to examine grief across cultures. The IPGDS consists of 13 items from the PG-13 and Structured Clinical Interview for Complicated Grief, and evaluates yearning, preoccupation, emotional distress, and functional impairment following the death of a loved one. Respondents indicate the frequency of each symptom in the past month on a 5-point Likert scale from 1 (Almost never) to 5 (Always). Scores are tabulated to indicate probable PGD diagnosis according to ICD-11 criteria. Killikelly and colleagues (2020) evidenced concurrent validity for the IGPDS with significant positive associations with other measures of grief (ICG-R), depression, anxiety, somatic distress, and trauma. They also found the measure could differentiate between those who experienced violent versus non-violent death. Factor analysis (*Killikelly et al., 2020; Tang & Xiang, 2021) identified a two-factor structure (Core Grief and Culturally Specific Symptoms).

The Revised Grief Experience Inventory (RGEI; Lev et al., 1993) was used in two studies using the same sample (*Anderson et al., 2005; Robinson & Marwit, 2006) and is a distillation of the original 135-item Grief Experience Inventory (GEI; Sanders et al., 1985). The RGEI was developed to improve the psychometric properties of the larger scale that used dichotomous true-false options. The RGEI’s 22 items are rated on a 6-point Likert scale, with statements such as “I tend to be more irritable with others since the death of my loved one.” Factors include Emotional Distress/Depression (6 items), Physical Distress (7 items), Existential Concerns (6 items), and Tension/Guilt (3 items). Internal consistency was strong (α′s = .95–.96).

The Hogan Grief Reactions Checklist (Hogan et al., 2001), used in two studies (DiMarco et al., 2001; W. Feigelman & Cerel, 2020), consists of 61 items rated on a Likert scale from 1 (Does not describe me at all) to 5 (Describes me very well) and six subscales: Despair (separation distress characterized by loneliness, depression, and sadness), Panic Behavior (physiological aspects of anxiety), Personal Growth (spiritual and existential development), Blame and Anger (bitterness and hostility), Detachment (avoidance of and withdrawal from others), and Disorganization (impaired concentration and trouble remembering). Lower scores indicate less pathological grief reactions. W. Feigelman and Cerel (2020) only used seven items from the Personal Growth subscale in their study.

The UCLA Grief Inventory (Layne et al., 2006), used in one study (Powell et al., 2010), is a 20-item self-report measure of maladaptive grief reactions and preceded the 28-item expanded version (Expanded Grief Inventory; Layne et al., 2001). Items are rated on frequency on a 5-point scale (0=Never to 4=Almost always). Sample items include “I miss [the person who died]” and “I feel more lonely since they died.” The original instrument assessed grief among adolescents but the UCLA Grief Inventory was used in an adult population in the included study (Powell et al., 2010), because the measure had been previously translated to Bosnian and the simpler language was determined ideal for the study sample with low levels of literacy. The UCLA Grief Inventory has three subscales: Normal, Traumatic, and Existentially Complicated Grief. Powell and colleagues (2010) found a three-factor solution fit their data best and demonstrated convergent and divergent validity; they did not provide internal reliability data.

The Brief Grief Questionnaire (BGQ; K. M. Shear et al., 2006), used in one study (Oexle & Sheehan, 2019), is a five-item clinician administered screener for CG. Originally developed when consensus criteria for CG were equivocal, the BGQ taps into two criteria sets and assesses frequency of experiencing trouble accepting the death, disruptions or impairment due to grief response, troubling images or thoughts of the death, avoidance of stimuli related to the person who died, and feeling cut off or distant from others. Respondents rate items using a 3-point Likert-type scale (0 = not at all; 1 = somewhat; 2 = a lot) and scores a “4” or greater are advised to undergo assessment for CG. Other studies have suggested qualitative descriptors based on BGQ scores; scores of 8 or higher determine that CG was likely, between 5 and 7 considered that CG was likely at a subthreshold level, and less than 5 likely negative CG diagnosis (Shear, 2006). Adequate internal reliability was found for the full scale (α =.84; Oexle & Sheehan, 2019).

The Clinical Global Impressions Scale-Severity (CGI-S; Guy, 1976) was constructed for use in National Institutes of Mental Health-sponsored clinical trials to provide a brief, stand-alone assessment of the clinician’s interpretation of patient functioning using a single question: “Considering your total clinical experience with the particular population, how mentally ill is the patient at this time?” with options rated on a 7-point Likert-type scale. A version of the CGI, modified to reflect CG severity (CG-CGI-S; M. K. Shear et al., 2005) in the preceding week was utilized in one study (Tal et al., 2017). The modified instrument determined the presence or absence of a CG diagnosis, and severity of symptoms using a scale analogous to the original CGI-S. Full descriptions of CG-CGI-S severity ratings are available from M. Shear et al., 2016). Tal et al. (2017) reported rater agreement for the CG-CGI-S was “moderate” (weighted kappa=0.53).

Modified version of the Complicated Grief Module.

A modified German version of the Complicated Grief Module (M. J. Horowitz et al., 2003; Langner & Maercker, 2005) was used in one study (*Kersting et al., 2007). Horowitz and colleagues (2003) developed the Complicated Grief Module as a structured clinical interview consistent with the Structured Clinical Interview for DSM-III-R—Non-Patient Edition (SCID-NP), which included a list of 30 symptoms of grief. Langner and Maercker (2005) adapted and translated the measure to German including 34-items mapping onto symptoms of grief, clustered into three categories: grief related intrusions (“unbidden memories or images of the deceased”), behavioral avoidance (“avoiding places that remind me of the deceased”), and difficulties adapting to the loss (“significant difficulty with new close relationships”). Symptoms are rated on a 7-point Likert scale from 0 to 6. In the German version, symptoms are listed as statements rather than questions (Langner & Maercker, 2005). Langner and Maercker (2005) replicated three factors and found adequate internal consistencies (α′s for Intrusions=.87, Avoidance=.77, and Failure to Adapt=.86), predictive validity according to receiver operating characteristic, divergent validity with other measures of psychopathology and convergent validity with other measures of grief (e.g., the TRIG German version). Horowitz et al. developed a diagnostic scoring algorithm, and the measure can be scored continuously.

Persistent Complex Bereavement Inventory (Core Grief Scale).

One subscale (Core Grief) from the Persistent Complex Bereavement Inventory (Lee, 2015) was used in one study (*Breen et al., 2021). The measure has 16 items mapping onto the DSM-5 diagnosis of PCBD, developed to facilitate research (Lee, 2015). In a general grief sample, Lee (2015) found a three-factor structure: Core Grief, Reactive Distress, and Social/Identity Disruption. The Core Grief subscale demonstrated good internal consistency (α′s from .89 to .91 in Lee’s sand .74 in *Breen et al., 2021. Lee found adequate test-retest reliability for the subscale (ICC = .54).

Measures of Grief-Related Constructs

The Grief Experiences Questionnaire (GEQ; Barrett & Scott, 1989) was employed in 12 studies (*Callahan, 2000; Feigelman et al., 2008, 2019; Gehrmann et al., 2020; Parker & McNally, 2008; Wojtkowiak et al., 2012); six used the same sample (Feigelman et al., 2009a, 2009b; Feigelman & Cerel, 2020; Feigelman & Feigelman, 2011; *Kõlves et al., 2019, 2020). Designed to assess a variety of grief responses, including those unique to suicide loss, the GEQ contains 55 self-report items using a Likert-type format (1=Never to 5=Almost Always). The GEQ includes 11 factors reflecting suicide bereavement: (1) Somatic Reactions; (2) General Grief; (3) Search for Explanation; (4) Social Support; (5) Stigmatization; (6) Guilt; (7) Responsibility; (8) Shame; (9) Perceived Rejection; (10) Self-Destructive Behavior; (11) Unique Reactions. Higher scores indicate greater grief challenges, whereas increasing subscale scores reflect a greater likelihood that a specific grief reaction has been experienced. One study translated the GEQ and performed a factor analysis reducing the items from 55 to 44 (α=.94) (Wojtkowiak et al., 2012). The GEQ showed adequate internal consistency (α=.77 to .87).

The Depressive and Anxious Avoidance in Prolonged Grief Questionnaire (DAAPGQ; Boelen & Van den Bout, 2010), used in five studies with unique samples (*Boelen et al., 2016; Boelen et al., 2019; *Cesur-Soysal & Durak-Batıgün, 2020; Eisma et al., 2020; Lenferink et al., 2020), evaluates anxious and depressive avoidance outlined in the cognitive-behavioral theory of CG and PGD (Boelen et al., 2006). The measure consists of a Depression Avoidance scale (“Since ____ died, I do much less of the things that I used to enjoy”) and Anxious Avoidance scale (“I avoid dwelling on painful memories connected to his/her death”). Respondents rate on an 8-point Likert-scale ranging from “not at all true for me” to “completely true for me.” Boelen and van den Bout (2010) reported internal consistency for the scales (α =.90 and .74), and found both scales accounted for unique variance in symptom levels of CG/PGD and were significantly positively associated with depression and PTSD, even when controlling for loss-related factors.

The Grief Cognitions Questionnaire (Boelen & Lensvelt-Mulders, 2005), used in four studies with unique samples (*Boelen et al., 2016; Boelen et al., 2019; *Cesur-Soysal & Durak-Batıgün, 2020; *Lenferink et al., 2020b), assesses negative grief-related cognitions on a 6-point Likert scale from disagree strongly to agree strongly. The measure has nine subscales: Self, Life, World, Future, Self-Blame, Others, Catastrophic Misinterpretations, Appropriateness of Grief, and Cherish Grief. Subscale internal consistencies ranged from .80 to .92. None of the included studies used all nine scales. The developers reported high internal consistency (α = .96), found that total and subscale scores predicted complicated grief, depression, and anxiety severity, found evidence for convergent and divergent validity with measures of positive thinking and pessimistic cognitions, and established that the measure could differentiate between those with and without complicated grief (Boelen & Lensvelt-Mulders, 2005).

The Death Imagery Scale (DIS; Rynearson & Correa, 2008) assesses grief-related imagery and was used in three studies (Williams et al., 2020); two used the same sample (Baddeley et al., 2015; Rheingold et al., 2015). The DIS consists of five self-report items that reflect death reenactment (“I experienced a fantasied replay of the dying”), rescue (“I experienced a fantasy of rescuing the person from dying”), revenge (“I experienced a fantasy of retaliation for this dying”), reunion (“I experienced a fantasy of reunion with the deceased person”), and remorse (“I experienced a fantasy that I should have somehow prevented the dying from happening”). Items are rated on a 4-point Likert-type scale; higher scores reflect greater frequency of death-related imagery. Recently, the DIS was expanded to 15 items due to problems with single item factors (e.g., construct validity, internal consistency reliability) and was labeled the Dying Imagery Scale-Revised (DIS-R; Williams et al., 2020). The DIS-R has three scales: Reenactment, Remorse, and Revenge. Inner item reliability was adequate (α = .71 to .74). Williams and colleagues’ (2020) found good internal consistency for the total scale (α = .95) and three factors (Reenactment_α = .95; Remorse_α = .95; Revenge_α = .95), and significant correlations with PTSD, depression, anger, and prolonged grief (Williams et al., 2020).

The Utrecht Grief Rumination Scale (UGRS; Eisma et al., 2014) was used in one study (Tang et al., 2019). Originally developed in Dutch, the UGRS measures grief-specific rumination, defined as repetitive and recurrent thoughts about the causes and consequences of the death and the negative feelings generated by the loss. The UGRS consists of 15 Likert-type items that assess frequency of ruminations (1=never to 5=very often). Five factors have been identified, with three items each including Reactions (thoughts about negative emotional reactions to the loss), Injustice (thoughts about the unfairness of the death), Counterfactuals (thoughts about the events leading up to the death), Meaning (thoughts about the meaning and consequences of the loss), and Relationships (thoughts regarding social support). Tang et al. (2018) reported adequate internal consistency (total α =.91; subscale α′s .65 to .73). Convergent validity was established with other measures of general rumination (r=.39). Test-criterion validity demonstrated that scores varied by kinship category of the decedent, and grief-specific rumination accounted for variance in anxiety, depression, and grief symptomatology, above and beyond covariates (time since the loss, cause of death, trait rumination, and trait mindfulness). Discriminant validity was adequate with higher scores among unexpected loss groups compared to those who expected the loss of a close other (Eisma et al., 2014).

Measures Developed for Specific Types of Loss

The Perinatal Grief Scale and Perinatal Grief Scale-Shortened.

The Perinatal Grief (PGS; Toedter et al., 1988) or its abbreviated version, the PGS-Shortened (Potvin et al., 1989), was used in 32 studies; 29 were unique samples. The PGS was developed based on the Texas Inventory of Grief (Zisook et al., 1982) as well as scholarly and clinical expertise on important dimensions of perinatal grief. The measure was used in German (referred to as the Munich Grief Scale; Beutel et al., 1995), Chinese, Swedish, French, Sinhala, Arabic, Spanish, and Indian. The original measure has 104 items and abbreviated measure has 33 items rated on a 5-point Likert scale (1=Strongly Agree to 5=Strongly Disagree). The measure has three subscales that evaluate increasingly more severe responses to perinatal grief: Active Grief subscale (predicts normative grief reactions; Potvin et al., 1989), Difficulty Coping (difficulty dealing with activities and other people, considered a more severe measure of depression), Despair scale (most severe and long-lasting form of distress related to perinatal loss). Studies reported good internal reliability for the entire scale (α=.80 to .95) and subscales (α=.86 to .92). Potvin et al. (1989) reported adequate test-retest reliability over a 12–15-month period for the total scale and subscales (r’s ranged from .55 to .66, p < .001), and good convergent validity with measures of depression (r=.79). The Active Grief subscale demonstrated expected lower convergence with depression (r=.62) than the Difficulty Coping scale (r=.80).

The Perinatal Grief Intensity Scale (*Hutti et al., 1998) was used in four studies (*Hutti et al., 1998, 2018); two from the same sample (*Hutti et al., 2013, 2015). It was developed based on theoretical constructs of perinatal grief and consists of 14 items. Factor analysis yielded three scales: Reality (perceived reality of pregnancy and fetus); Confront Others (ability to confront or interact with others about the miscarriage); and Congruence (between the actual experience and the desirable). Items are scored on a 4-point Likert scale ranging from Strongly Agree to Strongly Disagree. Cronbach alphas for the entire scale (.82) and subscales were good (.89, .83, and .71 for Reality, Confront Others, and Congruence scales, respectively).

The Pandemic Grief Scale (*Lee & Neimeyer, 2020) is a brief screening tool to identify those at risk of dysfunctional grief following COVID-19 related loss. The scale consists of five items derived from the PCBD scale and author observations of common reactions to COVID-19 related grief. Respondents rate the frequency they experience each thought, feeling, or behavior over the last 2 weeks on a scale of 0 (Not at all) to 3 (Nearly everyday). *Lee & Neimeyer, 2020 found a sensitivity rate of 87% and specificity rate of 71% (AUC=.87) for predicting functional impairment. The measure was positively correlated with suicidal ideation and substance use to cope with loss, and explained an additional 18% of the variance in functional impairment above and beyond depressive symptoms and generalized anxiety, evidencing the measure’s construct and incremental validity. Three studies with unique samples used this measure (*Breen et al., 2021; *Lee & Neimeyer, 2020), one of which evaluated the Turkish version (Evren et al., 2021) and replicated Lee and Neimeyer’s original validation study.

The Perinatal Bereavement Grief Scale (Ritsher & Neugebauer, 2002), used in two studies with unique samples (*Johnson et al., 2016; *Keefe-Cooperman, 2005), consists of 15 items derived from a literature review of theoretical, clinical, and counseling psychology and assesses grief and yearning for the lost pregnancy and baby. The majority of items evaluate yearning for the baby (7 items) and lost pregnancy (7 items), with the remaining item inquiring about physiological reactivity when thinking about the miscarriage. Items are rated on a 4-point Likert scale from rarely to 5 to 7 days. Ritsher and Neugebauer (2002) reported high internal consistency for the entire scale (α = .89) and good test-retest reliability. Factor analyses determined one underlying factor considered “yearning and pining for the deceased” (Ritsher & Neugebauer, 2002, p. 37). The authors also found convergent and divergent validity with measures of attachment and depression and social desirability. The authors translated the measure to Spanish and found cross-cultural validity with a Spanish speaking sample.

Measures of Normative Grief Reactions

The Core Bereavement Item (CBI; Burnett et al., 1997), used by one study (Momartin et al., 2004), was developed to measure “core” grief experiences that reflect normal grieving, in contrast to tools that tap into pathological grief. The CBI uses 76 items from the Bereavement Phenomenology Questionnaire to “provide a basis for detailed description of the evolution of the overall bereavement response” (p. 52; Burnett et al., 1997). The CBI consists of 17 items with frequency rated on a 4-point Likert scale (0=Never to 3=A lot of the time). Developers grouped items based on their theoretical valence and identified an Images and Thoughts subscale (7 items), Acute Separation subscale (5 items), and General Grief subscale (5 items). The study did not report psychometric properties of the scale (Momartin et al., 2004), but the developers found strong internal consistency (α=.91; Burnett et al., 1997). Others have identified a 2-factor solution and adequate reliability and validity in a general grief sample (*Holland et al., 2013).

Two-Track Bereavement Questionnaire (TTBQ; Rubin et al., 2009), used in one study (Levi-Belz, 2017), consists of 70 self-report items that draw on the theoretical and empirical literature associated with Rubin’s Two-Track Model of Bereavement (TTMoB), which takes a bifocal perspective on bereavement that includes the mourner’s general functioning (Track I) and relationship with the decedent (Track II). The TTBQ was designed to capture relational elements of the grief experience and has a five factor structure: Relational Active Grieving, Closeness and Positive Relationship with the Deceased, Conflictual Relationship with the Deceased, General Biopsychosocial Functioning, and Traumatic Perception of the Loss. The TTBQ demonstrated strong internal consistency (α′s =.77 to .91; Levi-Belz, 2017) and concurrent validity adequate with correlations between TTBQ factors and the ICG-R (.60–.84, Rubin et al., 2009).

Unnamed Study Specific Measures

Six studies developed and used unique measures specific to their research (*Avelin et al., 2013; *Hutti et al., 2015; *Kawashima & Kawano, 2019; *Reed, 1998; Smith et al., 2017; *Zhou et al., 2020). Two measures assess pathological grief symptoms (*Reed, 1998; *Zhou et al., 2020). *Zhou et al., 2020 created a composite measure that includes 10 items from the PG-13 and one item from a depression measure. Reed and colleagues’ (1998) measure consists of 32 items derived from bereavement literature and clinical work. Four measures assess symptoms specific to the type of loss (*Avelin et al., 2013; *Kawashima & Kawano, 2019; Smith et al., 2015, 2017). *Kawashima & Kawano, 2019 developed a seven-item measure with a unified factor structure (α=.84) based on the ICG and narratives from Japanese adults bereaved by suicide. *Avelin et al., 2013 developed a multiple-choice questionnaire for parents bereaved by stillbirth based on literature and two focus group discussions with fathers. Smith and colleagues (2015, 2017) developed two slightly different measures for their longitudinal study of grief following a mass shooting, one for each of their two time points. The Time 1 measure was derived from 10 items from the PCBD Checklist and the Time 2 measure was derived from 24 items from the ICG.

Discussion

The sequalae of traumatic loss is sorely understudied. However, over the past decade researchers and clinicians alike have paid greater attention to the unique impact of traumatic loss. This systematic review aimed to organize and examine the instruments and their psychometric properties used to assess grief reactions following adult traumatic loss. Findings note 31 measures of grief have been developed and researched to assess grief (i.e., pathological symptoms, measures of grief-related constructs, measures for specific loss groups, and normative reactions). Instruments included 15 measures of pathological grief symptoms, six measures of possible unique features of traumatic loss (e.g., grief rumination, death imagery), eight measures for specific loss groups (e.g., perinatal grief, pandemic grief), and two measures of normative grief reactions. The ICG (H. Prigerson et al., 1995) was the most widely used instrument in studies reviewed and includes five versions or adaptations in both self-report and interview formats. Authors of the ICG also developed the CGA-SR as a brief screener for PGD and later developed the PG-13. More recently, a revised version of the PG-13, the PG-13-R, was developed to reflect current consensus criteria for PGD (H. Prigerson et al., 2021).

One of the major limitations of the literature highlighted by this review is the heterogeneity of instruments assessing pathological grieving. Although core features of pathological grief diagnoses (CG, PG, PCBD, PGD) have remained consistent, language of symptom descriptions have shifted over time as criteria have been reevaluated and revised. Multiple versions of measures and the development of new ones pose a challenge for study comparison and require further psychometric analyses. As such, the majority of instruments measuring pathological grief identified by this review need to be evaluated to ensure congruence with these revised criteria for PGD within DSM-5-TR and ICD-11. Employing consensus measures can further our understanding of grief trajectories following traumatic loss relative to other types of loss, including the etiology of varied responses, and the rates of PGD within these populations. The newly developed PG-13-R is a promising instrument that corresponds to newly adopted consensus criteria for PGD, and should therefore be strongly considered relative to instruments that were developed prior to DSM-5-TR.

When selecting a measure for the purposes of research or clinical care to monitor symptoms, there are many considerations. One consideration is whether a loss specific measure should be used (e.g., for perinatal loss, loss associated with COVID-19). We found measures created for groups bereaved by specific loss (e.g., COVID-19) which is promising given the potentially unique features of deaths from specific causes (e.g., loved one dying alone in hospital). Researchers may also want to select a more commonly used measure such as the ICG or PG-13 when an aim is to compare findings with broader literature. As discussed above, consideration of the construct to be measured is of critical importance particularly if the clinician and/or researcher is interested in assessing for PGD.

This paper does not provide in-depth review of the strengths and weaknesses of each measure beyond available psychometric data given that for many measures, there were several versions of the measures (e.g., short-form versions, translated) and more importantly, that researchers and clinicians using this review to select measures may have different intended purposes. For example, a researcher interested in assessing symptoms of prolonged grief in adults bereaved by COVID-19 may find greater use in a pandemic specific measure even though another measure of grief may yield stronger psychometrics. Rather, we intend to provide a summary of the measures and the studies that employed them so that stakeholders can make informed decisions on which measures to use given the context-dependent nature of their studies. Within a measure, there were also several versions and adaptations that render making sweeping recommendations about one measure over another challenging.

Interestingly, half of the measures reviewed were developed to assess aspects of grief beyond diagnostic pathological grief response, including reactions that are possibly unique to traumatic forms of loss and are not captured in measures of general grief reactions, which is a strength of the extant literature. For instance, the Death Imagery Scale-Revised (DIS-R; Williams et al., 2020) measures grief-related imagery. Assessing these constructs, among others, to identify thoughts, images, and dreams can guide conceptualization and intervention strategies beyond diagnostic criteria alone. Importantly, these measures can continue to improve our understanding of the relationship between these grief-related constructs and new PGD symptomatology among traumatically bereaved populations to better understand the unique facets of traumatic loss responses. Furthermore, although a variety of loss types are considered traumatic, this review identified measures tailored for specific loss groups. For example, four grief measures reviewed focused on perinatal grief, which includes loss through stillbirth, miscarriage, or neonatal death. Among the perinatal loss grief measures, the Perinatal Grief Scale (PGS; Toedter et al., 1988) was the most widely used, followed by the Perinatal Grief Intensity Scale (PGIS; *Hutti et al., 1998). Research suggests that grief after perinatal loss differs from other types of loss in that guilt, self-blame, and sense of failure are more prevalent related to other significant loss populations (see Kersting & Wagner, 2012 for review). However, the utility of developing instruments tailored for specific loss populations versus validating existing measures within these populations remains unclear. Accordingly, and to the extent possible, future research should continue to assess features of the grief experience that may be unique to particular forms of loss and exacerbate or attenuate symptomatology and distress. For example, few studies examined facets of grieving and their relation to DSM-5-TR consensus PGD symptoms among individuals bereaved by COVID-19 infection or fatal overdose—two groups that are growing at alarming rates (e.g., Appa et al., 2021). Employing consensus-driven measures of grief among understudied and/or burgeoning populations of traumatic loss survivors will help to further validate these instruments (e.g., measurement invariance).

The studies reviewed were conducted across diverse samples and in a range of countries. For example, studies were conducted among African American, Native American, Caucasian American, French, Kurdish, Rwandan, Indian, Australian, Kenyan, Canadian, Dutch, Chinese, Korean, German, Norwegian, Japanese, Albanian, Israeli, Hispanic, Swedish, Arabic, Jewish, Italian, Cambodian, and Turkish samples. However, several of the newer measures related to PGD (i.e., IPGDS; PG-13-R) have yet to be examined among diverse populations, and very few studies in the current review used population-based samples. Given the potentially unique experiences of traumatic loss within different cultures and communities (e.g., refugees, war survivors, African American, mass violence survivors), the application of measures reviewed to diverse samples representative of the target population is a critical area for continued study.

This systematic review offers a thorough and organized approach to understanding the state of the grief assessment literature in the context of traumatic loss. However, there are several limitations. Traumatic loss survivors may experience other responses to loss including PTSD and depressive symptoms. By focusing our search on grief-specific assessments, we may have missed other instruments that may be useful in the assessment of the traumatic loss response. Therefore, it should be noted that this review is not comprehensive to all types of traumatic loss reactions. Related, traumatic loss populations were the focus of our queries. As such, there may be other valuable measures of relevance to these populations that have not yet been studied or used, such as those that assess the continuing bond between the mourner and decedent.

In sum, this paper offers an overview of assessment tools to guide the ongoing and future study of traumatic loss among adults. A significant number of measures have been utilized in the field over the past two decades, which is encouraging given that this population has historically been understudied and underserved. With the shift in diagnostic criteria for PGD, ongoing psychometric study is warranted with both existing and forthcoming measures.

Critical Findings.

Grief reactions to traumatic loss have been understudied and research is likely to increase with the inclusion of the diagnosis of PGD in ICD 11 and DSM-5-TR. This study systematically reviewed existing measures of grief following traumatic loss.

31 measures were identified and across the reviewed studies (N = 164) many adaptations and variations of the measures were used. The most commonly used measure was the ICG-R.

Half of measures identified across studies measures constructs associated with traumatic loss rather than solely focus on pathological symptoms of grief, lending opportunity to better understand a range of grief-related reactions.

Implications for Research, Practice, and Policy.

There is no “gold-standard” measure of grief among those who experienced traumatic loss potentially due to past lack of consensus on the pathological sequalae of traumatic loss and changes in proposed diagnostic criteria.

Across the literature, studies use many versions of the same measure and different measures to assess similar constructs. The lack of standardization of measures across researchers may pose problematic for comparison, interpretation, and replication of findings.

More research is needed as novel measures of PGD are developed with the inclusion of the diagnosis in DSM-5-TR.

Biographies

Author Biographies

Naomi Ennis, PhD is a Regional Clinical and Training Lead for the Ontario Structured Psychotherapy Program at Carepoint Health In Mississauga, Ontario and a former postdoctoral Fellow at the Medical University of South Carolina. Her research focuses on interpersonal risk factors for posttraumatic stress disorder, and enhancing methods to accessing evidenced-based psychological treatments.

Jamison Bottomley, PhD, is a postdoctoral fellow at the Medical University of South Carolina. His research has largely focused on the experience of exposure to suicide broadly, with a particular emphasis on how survivors of suicide loss adjust and find meaning in the wake of suicide loss.

Jessica Sawyer is a graduate student in the Clinical Mental Health program at the University of Memphis. Her main area of interest revolves around bereavement counseling, with a particular concentration on researching the implications Near Death Experiences and their aftereffects may have for experiencers and non-experiencers, alike, in the form of meaning making and constructivist therapy.

Angela Moreland, Ph.D., is an Assistant Professor at the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. Her research focuses on primary and secondary prevention of child abuse and risk factors for maltreatment among high-risk parents of young children (i.e., substance use, teen pregnancy); as well as dissemination and implementation of evidence-based practice for victims of interpersonal violence and their families.

Alyssa A. Rheingold, PhD is a licensed clinical psychologist and tenured Professor within the National Crime Victim’s Research and Treatment Center (NCVC) Division at the Medical University of South Carolina (MUSC). Dr. Rheingold’s overall research interests include examining the impact of victimization and trauma on a range of health outcomes and evaluating prevention and intervention strategies to promote post-trauma resiliency.