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. Author manuscript; available in PMC: 2024 May 1.
Published in final edited form as: Anxiety Stress Coping. 2022 Jul 19;36(3):275–290. doi: 10.1080/10615806.2022.2099545

Looking back and moving forward: Dimensions of coping flexibility divergently predict long-term bereavement outcomes

Sandy H Huang a,**, Jeffrey L Birk b, George A Bonanno a
PMCID: PMC9849482  NIHMSID: NIHMS1842153  PMID: 35852939

Abstract

Background and Objectives:

Bereavement is a serious public health concern. Some people suffer prolonged and debilitating functional impairment after the death of a loved one. Evidence suggests that flexibility in coping approaches predicts resilience after stressful life events, but its long-term effects after the unique experience of bereavement are unknown. Which strategies of coping flexibility predict better—or worse—adjustment over time for bereaved people and at what times?

Design and Methods:

The present study used path analyses to investigate longitudinal effects of forward-focus and loss-focus coping strategies on symptoms of persistent complex bereavement disorder (PCBD), depression, and posttraumatic stress disorder in a spousally bereaved adult sample (N = 248) at three time-points after the loss (~3 months, ~14 months, and ~25 months).

Results:

Forward-focus coping demonstrated adaptive utility overall, with sooner effects on PCBD than on depression. By contrast, loss-focus coping demonstrated a delayed-onset, maladaptive pattern.

Conclusions:

The findings contribute to the coping flexibility literature by suggesting that the adaptiveness or maladaptiveness of different coping strategies may depend on the context that requires coping. In particular, forward-focus coping may be substantially more advantageous than loss-focus coping in the context of bereavement. Implications, limitations, and future research directions are discussed.

Keywords: Coping flexibility, coping strategies, bereavement, PCBD, depression, PTSD

Introduction

Bereavement over the death of a loved one can be extremely painful and chronically debilitating for some people. Longitudinal studies investigating trajectories of adjustment after a loss (e.g., depression, prolonged grief, posttraumatic stress disorder [PTSD]) have identified approximately 10% of bereaved individuals with sustained disruption in functioning over time (Bonanno & Malgaroli, 2020; Bonanno et al., 2002; Galatzer-Levy & Bonanno, 2012; Lenferink et al., 2020; Maccallum et al., 2015; Mancini et al., 2011; Nielsen et al., 2019; Sveen et al., 2018; Zisook et al., 2014). Coping and emotion-regulation capabilities have long been posited as underlying mechanisms of resilience (i.e., minimal if any disruption to functioning) in the face of potentially traumatic events (PTEs; Bonanno, 2005; Mancini et al., 2011), and coping style, coping strategies, and coping ability have been shown to differentiate between individuals who adjust well after a PTE and those who do not (Bonanno et al., 2012; Bonanno et al., 2002; Galatzer-Levy & Bonanno, 2012).

In the context of bereavement, however, research on such individual differences has attracted much debate. Historically, emotional processing of the loss through effortful focus on thoughts, images, and memories associated with the deceased has been favored by the literature as a necessity for functional bereavement outcomes (Horowitz et al., 2003; Stroebe, 1992). By contrast, recent findings have suggested that functional bereavement outcomes may be more effectively influenced by behaviors focused on increasing restoration of normal life routines after the loss, such as planning for the future, engagement with the present moment, social interactions, optimism, and distraction (Bonanno & Burton, 2013; Bonanno et al., 1995; Caserta et al., 2009; Caserta & Lund, 2007; Delespaux et al., 2013; Lundorff et al., 2019; Shear et al., 2005).

The Dual Process Model of coping with loss (Stroebe & Schut, 1999; Stroebe et al., 2010) attempts to reconcile these seemingly opposing views on bereavement by attributing equal importance to processes that focus on the loss and on restoring life after the loss. Specifically, rather than the exclusive reliance on one focus over the other, the model posits that the fundamental factor for positive adjustment to bereavement is individuals’ oscillating use of both types of processes. Treatment approaches based on the Dual Process Model have demonstrated effectiveness (Chow et al., 2018; Lund et al., 2010; Newsom et al., 2017; Shear et al., 2014). Further, the overall assumptions behind this model have found empirical support across bereavement contexts (Albuquerque et al., 2017; Bennett et al., 2010; Bonanno, Wortman, et al., 2004; Caserta & Lund, 2007; Harper et al., 2015; Richardson, 2006; Wijngaards-de Meij et al., 2008). For example, prospective studies on the loss of a spouse (Bonanno, Wortman, et al., 2004) or a child (Wijngaards-de Meij et al., 2008) have found that individuals who were engaged in activities related to restoring and continuing with life after the loss (e.g., staying focused on current goals and plans) and also focusing on the loss (e.g., searching for meaning of the loss) demonstrated better adjustment outcomes, while those who had an exclusive inclination toward loss-focus coping exhibited a trajectory of prolonged grief with elevated and sustained symptoms over time (Bonanno, Wortman, et al., 2004), or higher levels of depression and grief (Wijngaards-de Meij et al., 2008).

Coping Flexibility and Bereavement

Related to the Dual Process Model’s emphasis on utilizing seemingly contradictory coping approaches, the literature on coping flexibility underscores the importance of being able to flexibly utilize differing strategies in accordance with situational demands. This line of research has documented the effectiveness of employing multiple coping and emotion regulation strategies to adjust to various PTEs (Cheng, 2001, 2003; Roussi et al., 2007). Specifically, experimental studies have demonstrated that the ability to enhance or suppress the subjective experience (Zhu & Bonanno, 2017) and expression of emotion (Bonanno, Papa, et al., 2004) in accord with contextual demands are associated with better adjustment cross-sectionally and longitudinally, respectively. Similar findings were found in a cross-sectional study of bereavement, whereby asymptomatic bereaved adults demonstrated better flexibility in emotional expression, compared to those with a complicated grief presentation (Gupta & Bonanno, 2011). Together, these findings consistently demonstrated that the ability to flexibly modulate emotions according to situational demands underlies positive adjustment to loss.

Crucially, and in contrast to the Dual Process model of bereavement, the flexibility perspective does not assume that both loss-oriented and restoration-oriented processes are necessary for positive adjustment. Rather, the flexibility approach holds that the efficacy of any given type of coping strategy, or category of strategies, will depend primarily on the demands of specific circumstances (Bonanno & Burton, 2013). Thus, in theory, the flexibility perspective leaves open the possibility that successful adaptation to loss may be related to both loss-oriented and restoration-oriented processes, only one of these processes, or neither.

Measuring Coping Flexibility

Bonanno and colleagues developed the Perceived Ability to Cope with Trauma (PACT) scale (Bonanno et al., 2011) to measure coping flexibility in everyday life in response to potential trauma (Bonanno & Burton, 2013; Bonanno, Papa, et al., 2004; Cheng, 2001; Kashdan & Rottenberg, 2010). Specifically, this self-report measure assesses one’s self-perceived ability to engage in two differing clusters of coping strategies involving cognitively and emotionally processing a specific PTE (e.g., remaining focused on the PTE, minimizing social interactions – collectively termed trauma-focus coping), and attending to the demands of moving forward with one’s normal life routine after the PTE (e.g., distracting from the PTE, attending to others – collectively termed forward-focus coping), respectively. Studies utilizing the PACT have consistently shown that these two different clusters of coping (trauma-focus and forward-focus) as well as their combination (assessed using a single flexibility score) each uniquely and positively contributed to adjustment after a PTE or major life stressor across multiple contexts, including among trauma-exposed adults in Israel (Bonanno et al., 2011) and Korea (Park et al., 2015), and American college students exposed to various stressors such as college transition (Bonanno et al., 2011; Galatzer-Levy et al., 2012).

Of note, however, somewhat different results were observed utilizing the PACT in the context of bereavement. As in PTE studies, bereaved adults reporting greater overall flexibility had lower grief symptoms and better adjustment (Burton et al., 2012; Knowles & O’Connor, 2015). Crucially, however, although greater forward-focus coping was associated in older bereaved individuals with a host of favorable outcomes (e.g., lower complicated grief symptoms, yearning, loneliness, perceived stress), trauma-focus (in this case loss-focus) coping was associated exclusively with high levels of grief symptoms (Knowles & O’Connor, 2015). Further, a cross-cultural study found that American and Chinese bereaved adults generally reported a greater ability to engage in loss-focus coping than married non-bereaved individuals, but those with complicated grief — as opposed to asymptomatic bereaved and non-bereaved individuals — reported weaker ability to engage in forward-focus coping (Burton et al., 2012). Together, these results suggest that the ability to focus on the loss may be characteristic of a normal bereavement experience, but it is the ability to focus on normal life routines after the loss, when necessary, that differentiates functional from pathological adjustment. Interestingly, the effect of forward-focus coping on grief symptoms only demonstrated significance earlier in the bereavement experience (Knowles & O’Connor, 2015), suggesting that forward-focus coping may have short-term effects in preventing the onset of symptom development. Although meaningful in clarifying how the specific coping approaches underlie adjustment, these studies were cross-sectional and examined data collected more than a year after the loss. No study has yet utilized the PACT to examine the differential effects of clusters of forward-focus and trauma-focus coping strategies measured shortly after the loss on longitudinal bereavement outcomes.

Potential Confounding Effects of Rumination

An additional limitation of previous research is that no bereavement study has examined the possible overlap of forward-focus and trauma-focus coping with rumination. Rumination is perseverative thinking regarding depressed mood, symptoms, and their potential causes and consequences, and it has been suggested as the central contributing factor of the onset of depression (Nolen-Hoeksema et al., 2008). However, several studies (e.g., Nolen-Hoeksema, 2000) have failed to show a significant predictive effect of rumination amongst individuals who were already depressed, suggesting that rumination may contribute to the onset but not necessarily the duration of depression (Nolen-Hoeksema et al., 2008). Bereavement studies have consistently documented associations between ruminative tendencies and depression, anxiety, PTSD, prolonged grief, and general distress (Eisma et al., 2015; Ito et al., 2003; Morina, 2011; Nolen-Hoeksema et al., 1997; Nolen-Hoeksema et al., 1994; for a review, see Eisma & Stroebe, 2017). These results suggest that rumination is characteristic of depression and may conflate the presentation of chronic depression and complicated grief when no data prior to the loss is available. In this regard, the potentially pervasive effects of rumination should be controlled and examined in relation to the effect of coping flexibility or its specific dimensions (forward-focus and trauma-focus coping) on bereavement outcomes.

The Present Study

To clarify the dimensions underlying the utility of coping flexibility in bereavement, in the present study we used path analyses to examine the longitudinal, differential effects of clusters of forward-focus and trauma-focus coping strategies measured three months after the death of a spouse on grief symptoms approximately one and two years later. Given that loss is the target event, trauma-focus coping will be henceforth referred to as loss-focus coping. We also examined paths involving depression and posttraumatic stress disorder (PTSD) symptoms. Importantly, network analyses have demonstrated that the causal system of symptoms differ between PCBD, depression, and PTSD (Maccallum et al., 2017; Malgaroli et al., 2018; Robinaugh et al., 2014), so symptoms one-year post-loss were used as a mediator in the current study to examine possible divergence in paths of effects between adjustment outcomes. As discussed above, because rumination may confound the presentation of depression and grief when prospective data prior to the loss is unavailable, we also examined rumination as a control variable. Given the reported association between rumination and the development of but not long-term maintenance of symptoms (Nolen-Hoeksema et al., 2008), we considered its effects shorter term with no direct contribution to the last time-point in our models (i.e., 25 months post-loss; more information below). The goal of the present study was to assess the associations between clusters of forward-focus and loss-focus coping strategies, and bereavement adjustment outcomes over time. Given the exploratory nature of the study, no specific hypotheses were proposed.

Method

Participants and Procedure

Two hundred eighty-two adults (67.5% female) between ages 25–65 who lost a spouse within the past 2–4 months were recruited from the community using fliers, public obituaries, support group referrals, and internet and newspaper advertisements. The mean age of participants was 55.74 years (SD = 6.80). The majority identified as Caucasian (91.3%) and had a college degree or above (63.7%). Most individuals were working full time (62.5%), with an expected median yearly family income of USD $95,000.00 (IQR: $52,000 - $140,000; see Supplemental Material for more demographic statistics). The mean length of conjugal relationship before loss was 25.19 years (SD = 9.98).

Participants provided informed consent, and completed questionnaires and interviews at three points at approximately 3 months (Time 1 [T1], M = 2.71 months, SD = 1.03 months), 14 months (Time 2 [T2], M = 14.45 months, SD = 0.99 months), and 25 months (Time 3 [T3], M = 25.26 months, SD = 0.65 months) since the death of their spouse. The sample size at T1, T2, and T3 was 249, 261, and 270, respectively, due to some participants providing data at later but not earlier time-points (e.g., provided data at T2 and T3 but not T1). The study was part of a larger project that was approved by the Institutional Review Board of Teachers College, Columbia University.

Measures

Coping flexibility.

Coping flexibility in relation to the loss was measured using the Perceived Ability to Cope with Trauma (PACT) scale (Bonanno et al., 2011). The PACT consists of 20 self-report items describing a range of coping behaviors that might be enacted following a PTE. For the current study, the target event was specified as the recent loss. Items are scored in terms of individuals’ self-perceived ability to engage in each behavior when necessary, on a 7-point Likert scale ranging from 1 (Not true) to 7 (Extremely true). The PACT yields two subscales representing clusters of distinct coping strategies: the Trauma Focus subscale (PACT-TF) consists of 8 different coping strategies related to the ability to process the target event, in this case the loss, including the ability to remain focused on the event and minimize social interactions (see Supplemental Material for details).

The Forward Focus subscale (PACT-FF) consists of 12 different coping strategies related to reducing the impact of the event and moving forward, including items associated with the ability to maintain current goals and plans and attend to others (see Supplemental Material for details). Higher score in either subscale indicates greater self-perceived ability to engage in the respective set of coping strategies. In previous research the PACT scale has demonstrated good factor structure, reliability, and validity in American, Israeli, and Korean samples with varying levels of PTE exposure (Bonanno et al., 2011; Park et al., 2015). Internal consistency reliability was adequate to good for the present study in which spousal loss was the target event (Cronbach’s α = 0.70 and 0.87 for the Loss Focus and Forward Focus subscales, respectively).

Rumination.

Ruminative patterns of thinking were measured using the Response Styles Questionnaire (RSQ; Nolen-Hoeksema, 1991) with 22 items that describe a variety of responses to depressed mood (see Supplemental Material for details). Participants scored items in terms of how frequently they generally engage in each behavior on a 4-point Likert scale ranging from 1 (Almost never) to 4 (Almost always), and a higher total score indicates more rumination. In previous research the RSQ has demonstrated good concurrent validity (Nolen-Hoeksema et al., 1990) and reliability (Bagby et al., 2004; Nolen-Hoeksema et al., 1990). Internal consistency reliability for the RSQ was excellent for the present study (Cronbach’s α = .932).

Structured Clinical Interviews.

Participants were administered structured clinical interviews to assess levels of grief, depression, and PTSD corresponding to the DSM-5 criteria (American Psychiatric Association, 2013) for persistent complex bereavement disorder (PCBD), major depressive disorder (MDD), and PTSD (see Supplemental Material for sources of interview items). Interviews were conducted by psychologists and advanced doctoral candidates in clinical psychology and videotaped. A randomly selected set of five interviews were recoded for reliability. Interclass correlation (ICC = .94) for absolute agreement indicated high inter-rater reliability. Symptom items were scored on a 3-point scale following the scoring criteria of the SCID (First et al., 2002); see Supplemental Material for details. Scores on relevant symptom items were summed to derive total symptom scores for PCBD, depression, and PTSD, respectively, with a higher score indicating more severe symptomatology.

Statistical Approach

Cases missing any T1 PACT or RSQ data or SCID data at more than two time-points were excluded from analyses, resulting in n = 248. After examining the suitability of the data for multiple imputation (see Supplemental Material for details), multiple imputation was performed on independent variables using LISREL for Windows with the following specifications: Expectation-Maximization (EM) algorithm, 200 iterations, and a convergence criterion of 0.00001. Mediation analyses were conducted utilizing path analysis — structural equation modeling (SEM) utilizing observed as opposed to latent variables — on IBM AMOS Version 24 for Windows.

SEM is recommended as the preferred method for mediation analysis as opposed to regression due to the following three advantages: 1) SEM allows variables to be both a cause and an effect in a model, which is an underlying characteristic of mediator variables, whereas regression requires a priori assignment of variables as either independent or dependent; 2) SEM takes into account simultaneous effects of multiple independent variables, mediators, and outcomes in one model and provides fit statistics for the entire model, while the regression approach requires combining results from individual equations to derive asymptotic variance and infer direct and indirect effects without indication of overall model fit; 3) SEM has much higher power than regression to test mediation effects (Baron & Kenny, 1986; Frazier et al., 2004; Gunzler et al., 2013; Hayes, 2009; Hoyle, 1994).

Maximum likelihood estimation was used for model analyses. Bias-corrected bootstrapping with a maximum limit of 5,000 iterations, which is widely recommended (Bollen & Stine, 1990; Fox, 2016; Hayes, 2009; MacKinnon et al., 2004; Preacher & Hayes, 2004), was used to derive the 95% confidence interval and two-tailed significance level for direct, indirect, and total effects. Separate models were derived for the three outcome variables of interest: PCBD, depression, and PTSD. Of note, forward-focus and loss-focus coping demonstrated non-significant changes over the three time-points in this study, suggesting trait-like stability (see Supplemental material for more information). Therefore, coping scores assessed at T1 only were included in each model.

Results

Descriptive Statistics and Correlation

Means and standard deviations of all independent and dependent variables are shown in Table 1 (see Supplemental Material for details on descriptive statistics). Bivariate Pearson correlations between independent and dependent variables are shown in Table 2. Loss-focus coping only had a significant positive correlation with forward-focus coping and T3 depression, whereas forward-focus coping consistently had a significant negative correlation with all symptom measures across time.

Table 1.

Descriptive Statistics of Variables

n Mean SD
T1 variables
 T1 PCBD 234 4.35 3.57
 T1 Depression 234 2.69 2.26
 T1 PTSD 234 4.38 3.55
 Forward-focus coping 248 60.61 11.93
 Loss-focus coping 248 41.36 7.40
 Rumination 248 42.70 12.32
T2, T3 variables
 T2 PCBD 227 2.41 2.89
 T2 Depression 228 1.50 1.83
 T2 PTSD 228 2.87 3.36
 T3 PCBD 236 2.11 2.67
 T3 Depression 236 1.36 1.90
 T3 PTSD 236 2.26 2.86
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Note. Overall sample N = 248. T1 = approximately three months post-loss; T2 = approximately 14 months post-loss; T3 = approximately 25 months post-loss.

Table 2.

Bivariate Correlations between Independent and Dependent Variables

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
1. Forward-focus coping r 1
n 248
2. Loss-focus coping r .145 * 1
n 248 248
3. Rumination r −.418 ** .047 1
n 248 248 248
4. T1 PCBD r −.406 ** .082 .601 ** 1
n 234 234 234 234
5. T2 PCBD r −.388 ** .000 .445 ** .587 ** 1
n 227 227 227 213 227
6. T3 PCBD r −.272 ** .107 .376 ** .468 ** .638 ** 1
n 236 236 236 222 215 236
7. T1 Depression r −.462 ** .043 .630 ** .693 ** .432 ** .371 ** 1
n 234 234 234 234 213 222 234
8. T2 Depression r −.365 ** .005 .485 ** .467 ** .677 ** .508 ** .472 ** 1
n 228 228 228 214 227 216 214 228
9. T3 Depression r −.322 ** .170 * .404 ** .350 ** .556 ** .689 ** .413 ** .566 ** 1
n 236 236 236 222 215 236 222 216 236
10. T1 PTSD r −.411 ** .074 .571 ** .779 ** .567 ** .482 ** .743 ** .507 ** .416 ** 1
n 234 234 234 234 213 222 234 214 222 234
11. T2 PTSD r −.335 ** −.032 .423 ** .558 ** .793 ** .557 ** .492 ** .760 ** .530 ** .649 ** 1
n 228 228 228 214 227 216 214 228 216 214 228
12. T3 PTSD r −.265 ** .096 .310 ** .463 ** .632 ** .759 ** .361 ** .560 ** .729 ** .551 ** .683 ** 1
n 236 236 236 222 215 236 222 216 236 222 216 236
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Note. Overall sample N = 248. T1 = approximately three months post-loss; T2 = approximately 14 months post-loss; T3 = approximately 25 months post-loss. PCBD = persistent complex bereavement disorder; PTSD = posttraumatic stress disorder. Bold values indicate statistical significance.

*

indicates p < .05

**

indicates p < .001

Test of Model Fit

Three models were derived to examine PCBD, depression, and PTSD symptomatology separately. Within each model, T1 PCBD, depression, or PTSD symptoms were included as control variables with direct paths linking only to their respective T2 symptoms. Similarly, rumination was included in each model as a control variable with a direct path linking to T2 symptoms only. Forward-focus and loss-focus coping, on the other hand, both have direct paths to T2 and T3 symptoms in each model. Additionally, four correlations were included: three between T1 symptoms and rumination and forward-focus coping, and one between forward-focus and loss-focus coping (see Supplemental Material for these correlations). Residuals for each mediator and outcome measure were also accounted for in each model.

Goodness-of-fit indicators such as the Chi-square statistic, Tucker-Lewis Index (TLI), Comparative Fit Index (CFI), root mean square error of approximation (RMSEA), and standardized root mean residual (SRMR) were used to determine model fit and identify the most parsimonious model. TLI and CFI scores greater than or equal to 0.95, RMSEA less than 0.06, and SRMR less than or equal to 0.08 would indicate acceptable model fit (Hu & Bentler, 1999; Schreiber et al., 2006). The three models on PCBD, depression, and PTSD each showed similarly good fit, as shown in Table 3. Although the depression model appears to be less parsimonious compared to the other models (i.e., ‘perfect’ TLI, CFI, and RMSEA), given the good SRMR and overall good fit statistics, no post-hoc modifications were conducted. Although the PTSD model had an RMSEA of 0.061, this value is close to the suggested boundary for adequate fit as described above, and other fit statistics indicate an overall good fit of the model. Thus, no post-hoc modifications were conducted. See Supplemental Material for the alternate models explored and rejected.

Table 3.

Goodness-of-fit Statistics for Path Analysis Models on PCBD, depression, and PTSD

PCBD Depression PTSD
Chi-square 4.823 3.442 7.667
df 4 4 4
p .306 .487 .105
TLI .993 1.005 .973
CFI .998 1.000 .993
RMSEA .029 .000 .061
SRMR .0287 .0229 .0254
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Note. N = 248 for all models. PCBD = persistent complex bereavement disorder; PTSD = posttraumatic stress disorder; TLI = Tucker-Lewis Index; CFI = Comparative Fit Index; RMSEA = root mean square error of approximation; SRMR = standardized root mean residual.

A substantial amount of variance in the mediators (i.e., T2 outcome measures) and dependent variables (i.e., T3 outcome measures) was accounted for by the independent variables in each model. As shown in Figure 1, the independent variables accounted for 42% of T2 PCBD, 33% of T2 depression, and 48% of T2 PTSD symptoms, respectively. More importantly, all included variables together accounted for 45% of T3 PCBD, 41% of T3 depression, and 51% of T3 PTSD symptoms respectively, indicating that the models explain substantial variability in each T3 outcome.

Figure 1.

Figure 1.

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Path diagrams illustrating T1 symptoms, rumination, and forward-focus and trauma-focus coping on T2 and T3 PCBD, depression, and PTSD symptoms respectively, with significant paths depicted by solid lines and significant standardized coefficients in bold.

Of note, participants’ gender did not have a significant influence on the path models on PCBD and depression (ps < .05). Although gender showed a significant moderation effect on the path model on PTSD (χ2 (7, N = 79) = 14.84, p = .038), bootstrap bias-corrected results indicated no significant difference in path effects between men and women (see Supplemental Material for details).

Effects of Control Variables

Once model fit was determined, the specific effects of T1 symptoms and rumination on T2 and T3 outcomes were examined. T1 symptoms that were added as a control variable in their respective models had significant direct and indirect effects on symptoms at T2 and T3 (see Supplemental Material for details).

Rumination was also included in all models as a control variable, but it only had a significant effect on depression symptoms. Specifically, rumination had a significant direct effect on T2 depression (β = 0.28, p = .001, 95% CI = [0.12, 0.44]) and a significant indirect effect via T2 depression on T3 depression (β = 0.15, p = .001, 95% CI = [0.06, 0.26]).

Effects of Forward-focus and Loss-focus Coping

PCBD symptoms.

Forward-focus and loss-focus coping had differential effects on PCBD outcomes. Specifically, the cluster of forward-focus coping strategies had a significant direct effect on T2 PCBD (β = −0.14, p = .015, 95% CI = [−0.24, −0.03]) and indirect effect via T2 PCBD on T3 PCBD (β = −0.09, p = .014, 95% CI = [−0.17, −0.02]), but no significant direct effect on T3 PCBD symptoms (see Supplemental Material for additional statistics). This suggests that forward-focus coping affects T3 PCBD symptoms primarily through T2 symptoms. Specifically, forward-focus coping predicted fewer T2 PCBD symptoms, which in turn predicted fewer T3 PCBD symptoms. The cluster of loss-focus coping strategies, on the other hand, only had a significant direct effect on T3 PCBD symptoms (β = 0.11, p = .041, 95% CI = [0.004, 0.21]), suggesting that loss-focus coping at T1 does not tend to predict T2 PCBD symptomatology but rather directly predicts more T3 PCBD symptoms.

Depression symptoms.

Neither forward-focus nor loss-focus coping had significant direct effects on T2 depression nor indirect effects on T3 depression. However, both forward-focus (β = −0.17, p = .001, 95% CI = [−0.28, −0.06]) and loss-focus coping strategies (β = 0.19, p < .001, 95% CI = [0.09, 0.29]) had significant direct effects on T3 depression. This indicates that neither forward-focus nor loss-focus coping appear to affect depression symptomatology at T2, but rather forward-focused coping directly predicts reduced T3 depression while loss-focused coping directly predicts increased T3 depression.

PTSD symptoms.

Interestingly, forward-focus coping strategies did not evidence any significant effect on T2 or T3 PTSD symptoms, suggesting that the ability to focus beyond a loss does not necessarily influence the development of PTSD over time. Loss-focus coping strategies, on the other hand, had a significant direct effect on T3 PTSD symptoms (β = 0.12, p = .014, 95% CI = [0.02, 0.22]), once again indicating that loss-focus coping does not necessarily affect symptomatology at T2, but similarly to its effects on PCBD and depression (described above), loss-focus coping predicts more PTSD symptoms directly at T3. Note that the statistical significance of results remained unchanged even after controlling for multiple testing across models using an adjusted-Bonferroni correction (Smith & Cribbie, 2013). For more information, see Supplemental Material.

Alternate Models Examined

Alternate models were explored with the following characteristics added separately to the originally proposed model: a) with rumination excluded from the model, b) with direct paths linking rumination and T1 symptoms to T3 symptoms, c) with direct paths linking T1 symptoms to T3 symptoms, and d) with direct paths linking rumination to T3 symptoms. All of the alternate models yielded model fit statistics that indicated a poorer fit, with over-fitting concerns, compared to the original model across all three adjustment outcomes (see Supplemental Material for details). Of note, alternate models c and d showed that neither T1 symptoms nor rumination had a significant direct effect on T3 symptoms (see Supplemental Material for details), supporting our inclusion of direct paths linking T1 symptoms and rumination to T2 symptoms only. Given the findings and our theoretical rationale as discussed above, the alternate models were rejected and our originally proposed model was accepted as final.

Discussion

The PACT has been used to examine longitudinal effects of coping flexibility on trauma outcomes (Bonanno et al., 2011; Park et al., 2015), but to our knowledge it has not been examined longitudinally in the context of bereavement, nor have its specific direct and indirect effects been examined on symptoms over time. The current study is the first to demonstrate that the PACT significantly predicts longitudinal bereavement outcomes. Importantly, present exploration of the specific directional effects underlying coping flexibility demonstrated that the ability to engage in distinct coping strategies representing forward-focus coping, generally predicted better adjustment after a loss. On the other hand, the ability to engage in coping strategies representing loss-focus coping consistently predicted worse adjustment. Specifically, our results suggest that having greater ability to focus on restoring life after the loss three months after the event is conducive to reducing short-term and long-term grief symptoms and long-term depression symptoms, whereas having a greater ability to process the loss three months after the event leads to more enduring psychopathology in the long run. These findings are inconsistent with the Dual Process Model’s notion that both types of coping are necessary for positive bereavement outcomes (Stroebe & Schut, 1999). However, these findings are generally consistent with the coping flexibility literature in suggesting that the efficacy of a coping approach or a set of approaches is not uniformly determined and instead depends largely on context (Bonanno, Papa, et al., 2004; Gupta & Bonanno, 2011; Zhu & Bonanno, 2017). Previous findings underscoring the utility of both forward-focus and trauma-focus coping examined PTEs (Bonanno et al., 2011; Park et al., 2015) and other stress-related events (Bonanno et al., 2011; Galatzer-Levy et al., 2012). By contrast, bereavement research that utilized the PACT has cast doubt on the adaptive utility of loss-focus coping in the particular context of coping with loss (Burton et al., 2012; Knowles & O’Connor, 2015). Our study extended previous cross-sectional findings by demonstrating longitudinally that the ability to engage in loss-focus coping exclusively predicts worse long-term outcomes. In this regard, it is likely that both coping approaches are adaptive and even necessary in the context of trauma and stress, but in the context of bereavement, only forward-focus coping may predict positive adjustment outcomes, while focusing on the loss may be exclusively maladaptive.

In examining the influences of each coping approach, forward-focus coping had divergent effects on PCBD, depression, and PTSD, which likely reflects the unique nature of each disorder. Extending previous cross-sectional research (Caserta & Lund, 2007), early ability to utilize forward-focus coping strategies was predictive of better long-term bereavement outcomes. Specifically, early forward-focus coping predicted fewer PCBD and depression symptoms at T3, implicating it as a generally effective coping strategy for a long-term decrease in bereavement-related psychopathology. Importantly however, the timing of the effects of forward-focus coping varied by symptom type. The effects of forward-focus coping on PCBD at T3 were indirect. Early forward-focus coping directly predicted reduced PCBD symptomatology at T2, which subsequently affected T3 symptomatology, denoting its effectiveness at more rapidly alleviating grief symptoms that lead to further symptom reduction over time. By contrast, early forward-focus coping did not evidence an effect on depression until T3, indicating a more gradual influence. These differing patterns may be attributable to phenomenal distinctions between prolonged grief and depression (Boelen & van den Bout, 2005; Bonanno et al., 2007), particularly the interrelationships of their symptoms as illustrated by network analyses (Maccallum et al., 2017; Malgaroli et al., 2018; Robinaugh et al., 2014). In this regard, it is possible that in the context of bereavement, efforts to focus on restoring life after the loss can cause more rapid alleviation of symptoms specific to grief, but this coping approach may take time to decrease symptoms that represent more general negative emotionality such as depression.

Interestingly, forward-focus coping did not influence PTSD symptomatology. A network analysis study examining the comorbidity of PCBD and PTSD in a bereaved sample showed that symptoms of hyperarousal and hypervigilance that are characteristic of PTSD clustered independently of PCBD, suggesting that such aspects of PTSD are distinct from grief (Malgaroli et al., 2018). Indeed, PTSD symptoms were shown to predict increased heart rate when bereaved individuals talked about the loss, whereas grief symptoms predicted the opposite (Bonanno et al., 2007), indicating that there are substantive differences in the physiological manifestation of the two disorders. Together, these findings suggest that PTSD symptoms, particularly those associated with autonomic responses, are distinct from PCBD. Thus, although forward-focus coping influenced long-term PCBD symptoms, its lack of effect on PTSD may be related to the relative independence of restoring normal routines and levels of autonomic arousal that is a fundamental characteristic of PTSD. This of course is speculation, and further research is required to clarify the distinction in autonomic arousal between PCBD and PTSD, and its association with forward-focus coping.

On the other hand, loss-focus coping consistently only directly and positively influenced T3 symptoms, suggesting that individuals tending to engage in loss-focus coping three months after the loss may not necessarily present with increased symptomatology in the short term, but nevertheless suffer more prolonged symptoms over time. This finding is in line with previous evidence associating excessive cognitive and emotional processing of a loss with dysfunctional adjustment outcomes over time (Bonanno, Wortman, et al., 2004; Caserta & Lund, 2007). Interestingly, loss-focus coping in the present study did not influence symptoms in the short term, which contrasts with a geriatric sample that demonstrated an association between loss-oriented coping and grief and depression symptoms regardless of time since loss (Caserta & Lund, 2007). The contrast may be due to age differences in the samples. However, because the geriatric study was cross-sectional, no causal effects can be inferred. Our study further extends these findings by demonstrating that the early ability to focus on the loss may seem to have no negative consequences in the short term, but nevertheless leads to increased psychopathology over time.

We included rumination as a control variable in the present study due to its possible overlap with loss-focus coping strategies. Reduced fit in alternate models from which rumination was omitted (see Supplemental Material) lent support for the theorized overlap. Rumination had an exclusive effect on depression but not on other adjustment outcomes, which supports the long-standing literature that rumination has a strong relationship with depression over and above other negative cognitive styles and traits (Nolen-Hoeksema et al., 2008). Although beyond the scope of this paper, it is important to note that when examining alternate models, rumination’s direct paths to T3 depression symptoms were not significant; its effect on depression remained significant only at T2, indicating that it does not directly affect the long-term maintenance of depression. This finding is in line with the previously proposed notion that rumination may influence the onset of depression symptoms but not their maintenance (Nolen-Hoeksema et al., 2008). In other words, although rumination may be a critical catalyst for depression, other underlying factors may maintain depression. On the other hand, rumination had no significant effect on PCBD or PTSD at T2 or T3 (see Supplemental Material for T3 results), which may be attributable to its negative correlation with forward-focus coping. Distraction — an aspect of forward-focus coping — has been posited as the opposite of rumination in its effects on dysfunctional adjustment outcomes, and the ability to effectively distract has been shown to reduce psychopathology (Nolen-Hoeksema et al., 2008). In this regard, rumination’s non-significant effects on PCBD and PTSD may suggest that outside of its integral relationship with depression, its effects may be rendered null by the ability to distract or focus on life and activities after the loss. Further research on rumination and forward-focus coping would help illuminate their relationship and differential influence on the development of psychopathology after a loss.

Limitations and Future Directions

This study has some notable limitations, including sampling bias, the use of self-report measures, potential symptom overlap between the rumination measure and the outcome measures, and separate analyses for each outcome measure. Additionally, the depression model’s ‘perfect’ TLI, CFI, and RMSEA statistics indicated that it may be less parsimonious compared to the other models. It was accepted without post-hoc modifications due to the good SRMR and overall statistics, especially compared to alternate models (see Supplemental Material), and its theoretical relevance. Nevertheless, this ‘perfect’ model may be attributable to the confounding effects of rumination, which possibly has mechanistic similarity to loss-focus coping and depression (Eisma et al., 2020). The different dimensions of rumination, including depressive and grief rumination (Eisma & Stroebe, 2017, 2021), were not explored in this study given the scope of the current investigation. However, future studies could augment our findings by examining the effects of specific types of rumination on loss-focus and forward-focus coping and bereavement outcomes.

Further, although not a limitation per se, the correlation between forward-focus and loss-focus coping was weak in this sample. In fact, it was much weaker in this sample compared to previous studies on trauma (Bonanno et al., 2011; Park et al., 2015) and a bereavement study utilizing a geriatric sample (Knowles & O’Connor, 2015). The difference could be attributable to the unique nature of bereavement. In addition, the geriatric bereavement study used data on average almost two years after the loss, which is much later than our study and possibly explains the difference in subscale correlations. Future studies should aim to confirm the factor structure of the PACT in the context of bereavement and replicate the current findings to clarify the correlation between subscales.

Another potential limitation pertains to the fact that the PACT examines individuals’ ability to engage in forward-focus or loss-focus coping when necessary, but it does not examine individuals’ ability to disengage from such coping strategies when necessary. Previous bereavement studies have shown that the relationship between negative emotional expressions and long-term outcomes varies by context (Coifman & Bonanno, 2010), suggesting that the ability to flexibly engage and, when necessary, disengage from negative emotionality underlies functional adjustment after a loss. Applying this notion to coping flexibility suggests the similar possibility that it may be that the ability to both engage and disengage from loss-focus coping when necessary underlies positive bereavement outcomes. The data from the current study cannot adjudicate these possibilities. Nevertheless, it would be informative to explore coping disengagement ability in future studies.

Finally, it should be noted that although the current study examined the predictive utility of coping flexibility on long-term bereavement outcomes, it was not possible to examine whether or in what way early bereavement may have influenced changes in coping flexibility. Repeated-measures assessment in the current study showed that neither forward-focus nor loss-focus coping ability changed significantly over time (see Supplemental Material), suggesting that coping flexibility may have trait-like stability, at least in the present sample during the two years after spousal bereavement. Nevertheless, it would be interesting and informative to further explore this possibility with pre-bereavement data in future studies.

Conclusions

This study is the first to our knowledge to demonstrate how specific dimensions of coping flexibility differentially influence long-term psychological adjustment after a loss. Specifically, early forward-focus coping ability was found to effectively reduce grief symptoms within one year of the loss, leading to better outcomes two years after the loss, while early loss-focus coping ability appeared to worsen grief symptoms over time. In this regard, these coping abilities have implications for understanding previously identified bereavement trajectories (Bonanno & Malgaroli, 2020; Bonanno et al., 2002; Galatzer-Levy & Bonanno, 2012; Lenferink et al., 2020; Maccallum et al., 2015; Mancini et al., 2011; Nielsen et al., 2019; Sveen et al., 2018; Zisook et al., 2014). Specifically, forward-focus coping may be predictive of membership in grief trajectories of resilience and/or recovery, while loss-focus coping may be predictive of a prolonged grief trajectory, given the detection of their predictive effects in our path models and the characteristics of the distinct trajectories. This has implications for the understanding and clarification of the role of coping abilities in adjustment trajectories after a loss.

These findings further suggest potential implications for the development of early preventative interventions soon after a loss. Although contemporary grief interventions have included both loss-focus and forward-focus processes (Boelen et al., 2007; Shear et al., 2005), such interventions are typically utilized relatively later in bereavement and have been applied exclusively to individuals who are unable to recover from grief. Our findings suggest, by contrast, that it may be possible to foster adaptive recovery earlier in bereavement with a concurrent emphasis on facilitating forward-focus processes and reducing loss-focus processes. This intriguing possibility suggests the importance of replicating and further exploring the dimensions of coping flexibility in the context of bereavement, and their relationship to bereavement-related psychopathology over time.

Supplementary Material

Supplemental Material

Funding:

This work was supported by the National Institute of Mental Health (R01 MH091034)

Footnotes

Disclosure of interest: The authors report no conflict of interest

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