TITLE: Complicated Grief Assessment for interdisciplinary research: An evidence-based protocol
AUTHORS: Raquel Martín-Ríos, Francisco J Leira-Castiñeira

[DESCRIPTION]
The Spanish Civil War caused a rupture in the social and cultural norms that had developed over a long period of liberalism. The violence that occurred during the three years of the conflict was significant. Following the coup, there was repression on both sides, leading to a vast number of people being killed and leaving their families grieving the loss of their loved ones. A repressive political atmosphere continued during the extended post-war period, resulting in a large number of widows and orphans. How did they experience this reality in a post-war context? What was the grieving process like? Were they able to overcome the loss of their family members, or did it lead to a social silence that manifested as hidden trauma, only surfacing with the arrival of democracy?

In the context of the Civil War, the grieving process was influenced by the unique circumstances in which it occurred. Survival as a way of life meant that the grieving process was not the same as what is typically studied in times of peace. This is why psychology can offer various hypotheses to enrich the academic debate within the field of psychology. It's worth noting that grieving in this context could be complicated due to the absence of a body to bid farewell to, or the lack of time and resources for traditional rituals and ceremonies. Additionally, the grieving process could be interrupted by the need to continue fighting or flee combat zones.

[STEPS]
SECTION: Theoretical framework
1. In grief research, different methods and approaches such as interviews, questionnaires and direct observation are often used to collect data on how people experience and process grief. These data are then analysed in order to identify patterns and trends that help to better understand the grief process as well as the factors that may influence the duration and severity of bereavement. In terms of theoretical approaches, several theories of grief have been examined, such as Elizabeth Kübler-Ross's five-stage model (denial, anger, bargaining, depression and acceptance) and William Worden's dual grief model (grief and coping). These theories have been used to provide a structure for understanding and analysing emotional responses and coping processes related to bereavement. However, research on grief in collective phenomena after traumatic events such as the Civil War is limited.

During the Civil War, people faced situations of extreme violence, such as fighting, bombings and killings. These events can lead to lasting emotional scars, such as post-traumatic stress disorder (PTSD), anxiety, depression and other mental health disorders. In addition to direct violence, trauma in civil war can also involve losing loved ones, destroying homes and communities, etc. These traumatic experiences may have long-term consequences for society as a whole. Hence the need to analyse trauma and grief in civil war through psychological research.

SECTION: A proposed protocol for the assessment of complicated bereavement
4. Clinical and socio-demographic data: demographic questionnaire that included data about themselves (age, gender, marital status...) and their decreased family member (life story, perceived institutional support, types of rituals conducted in memory of the deceased, commemorative acts for the departed...)

Texas Revised Inventory of Grief (ITRD; Faschingbauer, 1981). This questionnaire assesses the intensity of symptomatology associated with the bereavement experience through 21 items divided into two dimensions on a Likert-type scale (1= completely false to 5= completely true). The first subscale explores behaviour and feelings of the bereaved in the immediate aftermath of the death while the second subscale assesses current feelings in relation to the loss. For this study, only the items related to current feelings were examined, where higher scores reflect greater bereavement symptomatology. This instrument presents ample psychometric guarantees for the two subscales with Cronbach's alpha coefficient 0.75 and 0.86 respectively (Faschingbauer, 1981).

Carver's Brief COPE (Carver, 1997). This version considers 28 items and 11 subscales: (1) Emotional Support; (2) Active Coping; (3) Substance Use; (4) Mood; (5) Religion; (6) Self-Distraction; (7) Denial; (8) Disengagement; (9) Self-Incrimination; (10) Disconnection; and (11) Positive Reinterpretation.  It is answered on an ordinal Likert-type scale with 4 response alternatives (from 0 to 3), ranging from "I never do this" to "I always do this" with scores in between. The internal consistency of the scales ranges from α=0.59 to .93 (Morán et al., 2010).

Impact of Event Scale Revised (IES-R; Weiss and Marmar, 1997). It evaluates avoidance, hyperarousal and intrusion associated with PTSD by means of 22 items about the degree of distress and symptomatology generated by the exposure to the traumatic event in the last 7 days. It consists of 5 response options ranging from 0 (not at all or hardly at all) to 4 (very much) (Lería & Salgado, 2016). The total score of this scale can indicate normal psychological state (0-23), mild impact (24-32), moderate (33-36) and severe (> 37; Wang et al., 2020). This scale had an internal consistency (Cronbach's α) of .86 in the validation study (Báguena et al., 2001) and .95 in the present sample.

Perceived Stress Scale (PSS) (Cohen and Mermelstein, 1983) which consists of 14 direct questions (positive or inverse) about the levels of stress and control experienced in the last month by the subject (e.g., 'in the last month, how often have you been confident about your ability to handle your personal problems?'). The questionnaire is answered on a 5-point scale between 'never' and 'very often'; thus, higher scores indicate higher perceived stress.


  

SECTION: Vulnerability factors
3. Vulnerability factors encompass all the individual and situational factors of the presumed victim that can heighten and prolong the impact of psychological pain on their mental well-being. Grief during historical wartime events represents a complex and difficult process at both the individual and collective levels. The violent and chaotic nature of wars complicates the mourning process, as individuals did not always have the opportunity to properly say goodbye to their loved ones. Moreover, collective mourning was also a shared experience for soldiers and civilians, generating widespread grief in society. A number of factors are postulated as potentially affecting evaluation results

Strategies for positively reinterpreting challenging situations and events
Relying on social support and engaging in communal activities
Active engagement in life pursuits, whether professional, familial, or voluntary
Coping with everyday challenges
Previous exposure to victimizing experiences
Inadequate social support system
Unfavorable environmental response, which may involve a lack of credibility and assistance or excessive overprotection
Pre-existing psychological disorders, such as a deficiency in social support

SECTION: Traumatic event screening
2. The psychological assessment of a traumatic event and the detection of psychological distress involve a comprehensive process aimed at understanding the impact of the trauma on an individual's mental health.
SECTION: Traumatic event screening
2.1. Traumatic event screening

Evaluation of cognitive and emotional functioning helps assess how the traumatic event has influenced an individual's thought patterns, beliefs, and emotional responses. This may involve assessing cognitive distortions or maladaptive coping strategies. Also, it should be taken into account how the traumatic event has been impacted by the individual's daily functioning, relationships, and overall quality of life.
SECTION: Traumatic event screening
2.2. Detection of Psychological Distress

Evaluation of cognitive and emotional functioning helps assess how the traumatic event has influenced an individual's thought patterns, beliefs, and emotional responses. This may involve assessing cognitive distortions or maladaptive coping strategies.