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Complicated Spiritual Grief I: Relation to ComplicatedGrief Symptomatology Following Violent DeathBereavementLaurie A. Burke a & Robert A. Neimeyer aa Department of Psychology , The University of Memphis , Memphis , Tennessee , USAAccepted author version posted online: 25 Sep 2013.Published online: 11 Nov 2013.

To cite this article: Laurie A. Burke & Robert A. Neimeyer (2014) Complicated Spiritual Grief I: Relation to Complicated GriefSymptomatology Following Violent Death Bereavement, Death Studies, 38:4, 259-267, DOI: 10.1080/07481187.2013.829372

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Complicated Spiritual Grief I: Relation to Complicated GriefSymptomatology Following Violent Death Bereavement

Laurie A. Burke and Robert A. Neimeyer

Department of Psychology, The University of Memphis, Memphis, Tennessee, USA

Losing a loved one to violent death has been associated with poor mental healthoutcomes, including posttraumatic stress disorder, depression, and complicated grief(CG), a protracted, debilitating, and sometimes life-threatening reaction to loss. Inaddition, recent research suggests that traumatic loss can violate mourners’ basicassumptive worldviews, and can precipitate a spiritual crisis following loss, also knownas complicated spiritual grief (CSG). The present cross-sectional study investigated thesemultidimensional outcomes in a diverse sample of 150 grievers. The authors found that(a) violently bereaved individuals reported greater CG and CSG than did individualsbereaved by natural death; (b) CG and CSG were correlated across the larger sample,and yet are theoretically different constructs; and (c) specific cause of death (naturalanticipated, natural sudden, homicide, suicide, or fatal accident) differentially predictedlevels of CG and CSG. Implications of these findings for a clearer understanding ofspiritual coping in the wake of troubling loss are noted, as well as for intervention withmourners struggling with clinical complications.

Although grief is a nearly ubiquitous response to theloss of a loved one, research shows that loss as a resultof violence (i.e., homicide, suicide, or fatal accident)can manifest itself in a variety of ways (McDevitt-Murphy, Neimeyer, Burke, & Williams, 2012). Specifi-cally, when grievers struggle to adapt to their loss,bereavement distress can be expressed in terms ofdepressive (Williams, Burke, McDevitt-Murphy, &Neimeyer, 2011) or posttraumatic stress symptomo-tology (PTSD; Bonanno & Mancini, 2006), or as com-plicated grief (CG; Prigerson et al., 1995; Shear et al.,2011)—also termed prolonged grief disorder (PGD;Prigerson et al., 2009), a protracted, incapacitating,and sometimes life-threatening response to the loss ofa primary attachment figure. Research by Shear,Dennard, et al. (2006) also has suggested a less obvious,

yet troubling form of bereavement distress calledcomplicated spiritual grief (CSG), defined as a sense ofdiscord, conflict, and distance from God, and at timesfrom members of the survivor’s spiritual community.Recent studies with homicidally bereaved AfricanAmericans suggest that poor loss adaptation in the formof CG, specifically, prospectively predicts the develop-ment of CSG (Burke, Neimeyer, McDevitt-Murphy,Ippolito, & Roberts, 2011) and does so even whencontrolling for other forms of bereavement distress(i.e., PTSD and depression; Neimeyer & Burke, 2011).Thus, a link has been established between CG andsubsequent spiritual crisis in a sample of violentlybereaved adults. The goal of the present study is tofurther investigate these deleterious outcomes in thecontext of violent as opposed to natural death bereave-ment in a diverse sample of mourners.

VIOLENT DEATH BEREAVEMENT ANDCOMPLICATED GRIEF

Statistics compiled by the Centers for Disease Controland Prevention (2010) establish that approximately

Received 19 March 2013; accepted 1 July 2013.We gratefully acknowledge the grant support from the Tennessee

Board of Regents for the project African Americans in Bereavement

II: Assessment and Treatment of Complicated Spiritual Grief following

Traumatic Loss.Address correspondence to Laurie A. Burke, Department of Psy-

chology, University of Memphis, 400 Innovation Dr., 202 Psychology

Building, Memphis, TN 38152. E-mail: laburke@memphis.edu

Death Studies, 38: 259–267, 2014

Copyright # Taylor & Francis Group, LLC

ISSN: 0748-1187 print=1091-7683 online

DOI: 10.1080/07481187.2013.829372

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50,000 people die in the United States each year fromviolence-related injuries. Annually, over half of violentdeaths are suicides (56%), followed by homicides (30%),capital punishment and undetermined intent (13%), andunintentional firearm deaths (0.7%). Although notincluded in that total, approximately 31,000 people arekilled in motor vehicle accidents annually (NationalHighway Traffic Administration, 2009), and suchdeaths are typically classed as violent by researchersas they share features of suddenness and often grote-squeness with those arising from human intent. Whencombined with losses through natural disaster, war,and genocide, such experiences have resulted in deepemotional, psychological, physical, social, and spiritualsuffering for countless survivors in the wake of violentdeath.

Although many mourners report acute grief symp-toms following the death of a loved one, studies showthat most individuals experiencing nonviolent lossesare able to adapt to their bereavement within 1 to 2years (Bonanno & Mancini, 2006), and for the approxi-mately 45–50% of the bereaved population who arehighly resilient (Bonanno & Kaltman, 2001), the periodof debilitating suffering can be quite brief. However, fora subset of grievers, the loss of a loved one can bea crushing blow, leaving them severely disabled by CGsymptoms (e.g., profound separation distress, and aninability to accept the loss) that have been linked tolong-term physical and mental health problems,suicidality, and early mortality (Gilewski, Farberow,Gallagher, & Thompson, 1991; Latham & Prigerson,2004; Prigerson et al., 1997; Stroebe, Schut., & Stroebe,2007).

CG prevalence rates of 10–15% have been reported insamples of individuals grieving natural, anticipatedlosses, but recent studies show much higher rates in vio-lently bereaved samples (e.g., 31% of traumaticallybereaved Bosnian refugees [Momartin, Silove,Manicavasagar, & Steel, 2004]; 44% of survivors ofterrorist attacks [Shear, Jackson, Essock, Donahue, &Felton, 2006]; 56% of homicidally bereaved AfricanAmericans [McDevitt-Murphy et al., 2012]; 70% ofsuicide survivors [Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004]). As a consequence of these and otherstudies (e.g., Clieren, 1993; Currier, Holland, Coleman,& Neimeyer, 2006; Gamino, Sewell, & Easterling,2000; Keesee, Currier, & Neimeyer, 2008; Murphy,Johnson, Wu, Fan, & Lohan, 2003), violent death hasbeen classified as an established risk factor for compli-cated grief (Burke & Neimeyer, 2012a). Such findingshave not been entirely consistent, however, with somestudies reporting null findings (Feigelman, Jordan, &Gorman, 2009; Prigerson et al., 2002; van der Houwen,2010).

COMPLICATED SPIRITUAL GRIEF

Spiritual beliefs and religious practices can be significantcoping resources in dealing with loss (Hays & Hendrix,2008; Wortmann & Park, 2008). In their review of theempirical literature, Burke and Neimeyer (2012b) foundthat religious beliefs and practices generally wereassociated with reduced distress in spiritually inclinedindividuals, as well as with good decision making,healthy living, and altruistic behaviors. Likewise, inmonotheistic traditions, Kirkpatrick (1995) argued thatfor many individuals ‘‘God functions psychologicallyas an attachment figure’’ (pp. 451–452) by represent-ing a safe haven and a secure base, much in the way thata primary caregiver does for the young child (Bowlby,1980). Of course, not all believers regard their rela-tionship with God as safe and secure. In fact, althoughfaith generally is a source of solace more than strain,Exline and Rose (2005) found that when suffering life’strials it is common for many believers to at least partlyblame God, even when there is another knownperpetrator (e.g., in the case of homicide loss). Moreover,although Exline and Rose (2005) found that fleetinganger toward God is commonplace among religiouslyinclined mourners, protracted anger was indicative ofpoor adaptation. Results from other studies convergewith this conclusion and indicate that severe lifestressors like traumatic bereavement could severelychallenge one’s faith in turn.

A pilot study conducted by Shear, Dennard, andcolleagues (2006) illustrated the role of bereavementin affecting one’s spiritual well-being. The team ofchurch leaders and researchers monitored the griefresponses of 31 African American bereaved congre-gants, finding that although the effects of loss onthe griever’s faith ranged from ‘‘faith stronger thanever’’ to ‘‘faith seriously shaken,’’ 19% of the parti-cipants reported experiencing some degree of negativeshift in their faith as a result of the loss. Extendingthese findings, Burke et al. (2011) conducted a longi-tudinal study of 46 homicidally bereaved AfricanAmericans, finding that CG prospectively predictedspiritual distress 6 months later, but not vice versa,arguing for conceptualizing them as separate con-structs. In a follow-up study with the same sample,Neimeyer and Burke (2011) discovered that althoughall forms of bereavement distress were correlated withspiritual crisis, only CG uniquely predicted the laterdevelopment of an attachment struggle with God(i.e., CSG), beyond the variance explained by PTSDand depression, as well as the number of months sincethe loss. However, these results require replicationwith further samples that are diverse in both ethnicityand cause of death.

260 L. A. BURKE AND R. A. NEIMEYER

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AIMS OF THIS STUDY

Insofar as research indicates that violent death lossposes an increased risk of a severe grief response withadditional risk of spiritual crisis arising as a byproduct,we hypothesized that violent loss would predict bothCG and CSG in a diverse sample of bereaved adults suf-fering various types of losses, and that the two forms ofmaladaptive bereavement response would be related butdistinguishable constructs. Some investigations of therelation between levels of bereavement distress and typeof death indicate that the traumatic experience of havinga loved one murdered exceeds other types of violence interm of severity of distress for the survivor (Currier,et al., 2007; Murphy, et al., 2003). Thus, as an additionalaim, we sought to establish whether specific causes ofdeath (natural anticipated, natural sudden, homicide,suicide, or fatal accident) differentially predicted levelsof CG and CSG in our sample.

METHOD

Participants

Following the university’s Institutional Review Board’sapproval, we collected data from several samples ofbereaved adults who were diverse in terms of ethnicity,type of loss, and church affiliation, and who met thefollowing inclusion criteria: 18 years old or older,endorsement of the Christian faith tradition, bereavedwithin the past 10 years (with a mean postloss durationof 3.5 years (M¼ 40.6 months; SD¼ 2.6 months), as CGis by definition a long-term condition whose outerbounds are yet to be established. We recruited a totalof 150 bereaved individuals from community colla-borators that included (a) several large, local churches(n¼ 75; 50%); (b) Victims to Victory, a local, faith-basedhomicide survivor advocacy agency (n¼ 9; 6%); as wellas (c) psychology undergraduate classes at a large,mid-South, state university (n¼ 66; 44%). Specifically,we recruited from several churches in the Memphisarea that serve (a) predominantly African Americancongregations, (b) primarily Caucasian congregations,and (c) multiracial congregations to maximize diversityin the sample.

After securing support of community collaborators,we recruited participants through the use of brochureshanded out by church or agency staff or the projectcoordinator, with interested individuals being directedto the project’s registration website or to call or emailto schedule an assessment session. We offered no mon-etary remuneration; however, we offered participatingchurches bereavement-related education and follow-uppresentations on the results of the study in appreciationfor their support. Participants in the college student

cohort were provided an Internet link that directed themto a screening survey that established their eligibility toparticipate, followed by in-person or online administra-tion of the study questionnaires. Students were offeredcourse credit for completion, and informed of counsel-ing resources available on campus should they wish tospeak about any aspect of their grief experience. Ethnicdiversity was assured by the mixed-racial nature and sizeof the university student body as a whole.

Procedures

Participants who met inclusion criteria completed a setof paper-and-pencil measures or an online survey, withquestionnaires counterbalanced in order of administra-tion. Measures included the following:

Inventory of Complicated Grief-Revised

The Inventory of Complicated Grief–Revised(ICG-R; Prigerson & Jacobs, 2001) assesses griefsymptoms indicative of long-term dysfunction inbereavement. This 34-item scale uses a series of 5-pointLikert-style ratings of the frequency of various symp-toms ranging from almost never to always. Representa-tive items include ‘‘Memories of _______ upset me’’; and‘‘I think about _______ so much that it can be hardfor me to do the things I normally do.’’ The ICG-Rhas been shown to have high internal consistency(Cronbach’s a¼ .95) and test-retest reliability (r¼ .80)in a sample of bereaved college students (Schnider,Elhai, & Gray, 2007), and high internal consistency(a¼ .95) in samples of homicidally bereft African Amer-icans (Burke, Neimeyer, & McDevitt-Murphy, 2010;Laurie & Neimeyer, 2008). The scale’s construct validityhas been supported by its convergence with othervalidated measures of grief (Keesee, et al., 2008; Laurie& Neimeyer, 2008), as well as with interviewer ratings ofCG (Prigerson, et al., 2009). In the present sample,the ICG-R also had high internal consistency (a¼ .96).

Brief RCOPE

The Brief RCOPE (Pargament, Smith, Koenig, &Perez, 1998) is a reliable and valid measure of religiouscoping, using 14 items and two subscales to assess bothpositive religious coping (PRC; e.g., ‘‘Focused on religi-on to stop worrying about my problems’’) and negativereligious coping (NRC; e.g., ‘‘Felt punished by God formy lack of devotion’’). The Brief RCOPE has shownadequate to high internal reliability for both subscales(a¼ .80 and .69, respectively) in three distinct cohortsof distressed individuals (Pargament, et al., 1998), andin samples of violently bereaved African Americans(Burke et al., 2011; PRC and NRC, a¼ .88 and .79,respectively). Alphas for the PRC and NRC subscalesin this study were both .89, respectively.

COMPLICATED GRIEF AND COMPLICATED SPIRITUAL GRIEF 261

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Religious Coping Activities Discontent Subscale

The Religious Coping Activities Discontent Subscale(RCA; Pargament, Ensing, Falgout, & Olsen, 1990) usesa 4-point Likert scale to assess spiritual struggle with thefollowing items: ‘‘Felt angry with or distant from God,’’‘‘Felt angry with or distant from members of thechurch,’’ and ‘‘Questioned my religious beliefs andfaith.’’ Pargament and colleagues (1990) reported ade-quate to high internal consistency for each subscale intheir sample (a¼ .61 to .92). The Discontent subscaleshowed adequate internal consistency in our analyses(a¼ .82).

Background Variables

We assessed routine demographic variables such asage, gender, education, annual income, relationshipstatus (whether the participant is currently involved ina romantic relationship), relationship type (i.e., parti-cipant’s relationship to the deceased), time since loss(TSL), cause of death (i.e., natural anticipated, naturalsudden, homicide, suicide, or fatal accident), and violentversus nonviolent loss. In addition, we asked ‘‘Howoften were you in contact with this person before heor she died?,’’ providing the following response options:two to seven times per week, once per week, every otherweek, once per month, less than once per month.

RESULTS

Our results aligned with other researchers (Exline &Rose, 2005), in that spiritual struggle was commonlyexperienced among Christians in our study. Descrip-tively, we discovered that out of 150 respondents 87(58%) endorsed CSG in terms of NRC scores, and 66(44%) endorsed CSG in terms of Discontent scores.Table 1 highlights the descriptive statistics for the entiresample, and for violently- and non-violently bereavedcohorts considered separately. Of the total sample,12% (n¼ 18) had elevated (1 SD above the mean)NRC scores (i.e., >8.16), and 15% (n¼ 23) had elevatedDiscontent scores (i.e., >3.55). In the case of CG, viol-ent death survivors showed lower levels of CG com-pared to Burke et al.’s (2010) sample of AfricanAmericans grieving the loss of a loved one to homicide(M¼ 79.6; SD¼ 24.5). Both violently and nonviolentlybereaved individuals in our sample exhibited lowerlevels of PRC than did homicidally bereaved adults inBurke et al.’s (2011) study (PRC M¼ 17.8; SD¼ 3.9);however, NRC scores from our violently bereavedcohort were on par with the previous sample (NRCM¼ 5.3; SD¼ 5.0). In terms of Discontent, whole sam-ple scores from our study were similar to Pargamentet al.’s (1990) sample of individuals responding to a

recent stressful event (e.g., sudden illness or injury,death of loved one; M¼ 1.37; SD¼ .60).

Because subscales of religious coping were highlyskewed in our sample, before running our analyses wetransformed the PRC variable using the ‘‘reflect andsquare root’’ transformation method, and transformedthe NRC variable using the logarithm (with zero values)method, as suggested by Tabachnick and Fidell (2007).Table 2 shows statistically significant associationsbetween the major variables in the study. Pearson corre-lations revealed that CG and PRC were uncorrelated(r¼ .09, p¼ .28), and that CG and CSG were correlatedand yet distinguishable constructs (CG and NRC,r¼ .40, p< .001; CG and Discontent, r¼ .28, p¼ .001).

Table 3 shows results of hierarchical multiple regre-ssion analyses of CG on CSG total scores, controllingfor age, education, income, and violent death loss. Con-sistent with previous studies, CG was positively associa-ted with NRC, F(6,138)¼ 10.54, p< .001, CG ß¼ .36,p< .001; and Discontent, F(6, 138)¼ 4.51, p< .001,CG ß¼ .27, p< .003. Likewise the association betweenCG total scores and individual CSG items is shown inTable 4. All individual items on both the NRC andDiscontent subscales were positively correlated withCG, even after controlling for correlated backgroundvariables. However, when we paired the longing=yearning variable from the ICG-R with individual itemson scales of CSG, we found no association. Specifically,all NRC and Discontent items proved nonsignificant,with the exception of the following, which approachedsignificance: NRC Item 9, ‘‘Felt punished by God formy lack of devotion,’’ F(5, 139)¼ 5.21, p< .001; CGItem 5, longing=yearning, ß¼ .15, p¼ .08; NRC Item10, ‘‘Wondered what I did for God to punish me,’’F(5, 139)¼ 5.07, p< .001, longing=yearning, ß¼ .14,p¼ .10.

Our preliminary analyses ensured homogeneity ofregression slopes and homogeneity of variances. Thus,we proceeded with tests to see if violently bereavedindividuals have higher levels of CG and CSG than non-violently bereaved individuals, finding consistent sup-port for this hypothesis across measures. Analyses ofcovariance (ANCOVAs) with education, TSL, andcontact as covariates showed a statistically significantdifference between the two groups on CG scores, F(1,143)¼ 18.65, p< .001, partial eta¼ .12; violent (n¼ 36)unadjusted M¼ 69.08, SD¼ 27.96, adjusted M¼ 66.53,SD¼ 3.40; and nonviolent (n¼ 111) unadjusted M¼48.68, SD¼ 18.29, adjusted M¼ 49.50, SD¼ 1.92. Like-wise, ANCOVAs with age, education, income, and TSLas covariates showed a statistically significant differencebetween the two types of loss on NRC scores, F(1,138)¼ 11.88, p< .001, partial eta¼ .08; violent (n¼ 34)unadjusted M¼ 5.71, SD¼ 5.93, adjusted M¼ 5.89,SD¼ .81; nonviolent (n¼ 110) unadjusted M¼ .2.74,

262 L. A. BURKE AND R. A. NEIMEYER

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SD¼ 4.18, adjusted M¼ 2.68, SD¼ .43. Finally,ANCOVAs with age and TSL as covariates showed astatistically significant difference between violent andnonviolent death loss on Discontent scores, F(1, 14)¼5.82, p¼ .02, partial eta¼ .04, violent (n¼ 35) un-adjusted M¼ 2.0, SD¼ 2.18, adjusted M¼ 2.21, SD¼.36; nonviolent (n¼ 110) unadjusted M¼ 1.26, SD¼2.12, adjusted M¼ 1.20, SD¼ .20).

Table 5 illustrates how cause of death differentiallypredicted CG, F(1, 140)¼ 7.47, p< .001, partial eta¼.18. Specifically, we found differences between naturalanticipated death (M¼ 45.61, SD¼ 16.18; n¼ 74) onthe one hand and both homicide (M¼ 73.15, SD¼ .03,n¼ 20) and suicide deaths (M¼ 76.60, SD¼ 28.75,

n¼ 5) on the other, as well as between natural suddendeaths (M¼ 54.71, SD¼ 20.53, n¼ 38) and homicidedeaths. Accidental death (M¼ 58.27, SD¼ 19.11, n¼11) was intermediate in the comparison and not reliablydifferent from any other cause of death. In relation toCSG, a statistically significant difference, F(1, 135)¼3.64, p¼ .003, partial eta¼ .10, between natural antici-pated deaths (M¼ 2.39, SD¼ 3.65; n¼ 75) and accident(M¼ 7.27, SD¼ 7.27, n¼ 11) in terms of NRC scoreswas found. We found no other differences between othercauses of deaths (homicide, M¼ 5.05, SD¼ 5.28, n¼ 21;suicide, M¼ 4.40, SD¼ 4.39, n¼ 5; natural suddenM¼ 3.23, SD¼ 2.98, n¼ 38) in terms of NRC scores.Finally, we found no statistically significant difference

TABLE 1

Descriptive Statistics for Bereavement Outcome, Religious Coping, Spiritual Crisis, and Background Variables in

a Diverse Sample of Grievers (n¼150)

Measures Range M (SD)

Whole sample

M (SD)

Non-violently

bereaved M (SD)

Violently

bereaved M (SD)

Complicated grief 0–150 53.5 (22.6) 48.7 (18.2) 68.2 (28.1)

Positive religious coping 0–21 14.5 (5.3) 14.5 (5.4) 14.6 (5.3)

Negative religious coping 0–21 3.4 (4.8) 2.7 (4.2) 5.6 (5.8)

Discontent 0–9 1.42 (2.1) 1.3 (2.1) 2.0 (2.1)

Demographic variables

Time since loss 7 days–9.9 years 3.4 years (2.6 years)

Age 18–76 years 33.3 years (17.75 years)

% (n)Race

African American 40.7 (61)

Caucasian 54 (81)

Other 5.3 (8)

Sex

Female 82 (123)

Male 18 (27)

Kinship to deceased

Spouses 6.7 (10)

Mothers 6.7 (10)

Fathers .7 (1)

Sisters 3.3 (5)

Children 14.1 (30)

Extended family 38.5 (58)

Friends=girlfriends=boyfriends=other 24 (36)

Marital Status

Married 24 (36)

Single 62 (93)

Separated=divorced 7.3 (11)

Widowed 6 (9)

Education

<High school 1.4 (2)

High school=GED 12 (18)

Some college 58.7 (88)

College 15.3 (28)

>College 12.7(19)

Income

<$24,999 52.7 (79)

$25,000–49,999 16.7 (25)

>50,000 28.6 (43)

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between types of death in relation to Discontent scores,F(1, 139)¼ 2.06, p¼ .09, partial eta¼ .06.

DISCUSSION

Relatively little research has been conducted on the con-junction of CG and CSG, generally, or in the lives ofindividuals bereaved by violent causes, specifically.Consistent with previous studies (Burke et al., 2011;Neimeyer & Burke, 2011), we found that two forms ofspiritual responses, PRC and NRC—one characteristi-cally considered positive and one negative—relatedquite differently to bereavement outcome. On the one

hand, in this study, use of religion as a positive resourcein coping proved unrelated to adjustment to loss,whereas maladaptive religious coping was consistentlyrelated to elevated grief, replicating findings of Burkeand her colleagues (2011) with a sample of homicide sur-vivors. This suggests that across multiple studies, PRC isunrelated to loss accommodation, whereas NRC is mostproblematic for individuals who have lost a loved one toviolent means. Viewed from one perspective, this couldsuggest that attempting to cope with loss through posi-tive recourse to one’s religious beliefs does little to bluntthe sharp pain of grief. However, the lack of correlationof these two variables could as legitimately suggestthat mourners may continue to reach out to God and

TABLE 3

Hierarchical Multiple Regressions Showing Associations Between Complicated Grief and Complicated Spiritual Grief Total Scores

in a Diverse Sample of Grievers (n¼ 150)

Outcome

Step 1 Step 2

Variable Total R2 DR2 b Variable Total R2 DR2 b Overall F

NRC Age .22��� .22� �.28� Age .31��� .10��� �.25�� 10.54���

Education �.04 Education .03

Income �.13 Income �.13þ

Contact �.20�� Contact �.11

Violent=non .30��� Violent=non .19�

CG .36���

Discontent Age .11�� .11�� �.28�� Age .16�� .07�� �.26�� 4.51���

Education .01 Education .06

Income .01 Income .01

Contact �.15þ Contact �.08

Violent=non .23�� Violent=non .15þ

CG .27��

Note: NRC¼negative religious coping; Complicated spiritual grief¼NRC and Discontent scores; Contact¼preloss frequency of

contact with the deceased; Violent=non¼ violent vs. nonviolent death; CG¼ complicated grief.yp> .05. �p< .05. ��p< .01. ���p< .001.

TABLE 2

Intercorrelations of Bereavement Outcome, Religious Coping, and Background Variables in a Diverse Sample (n¼ 150)

Variables 1 2 3 4 5 6 7 8 9 10 11 12

1. CG — .09 .40�� .26�� .11 �.03 �.25�� �.13 .03 �.06 �.25�� .37��

2. PRC — .01 �.12 .23�� .21� �.01 .04 �.07 �.04 �.14 .01

3. NRC — .63�� .05 �.19� �.23�� �.23�� .10 .06 �.16 .27��

4. Discontent — .06 �.19� �.12 �.19 .01 �.01 �.06 .14

5. Gender — �.09 �.10 �.07 .01 .10 .08 .07

6. Age — .37� .28�� �.02 .30�� �.30�� .22��

7. Education — .32�� �.06 .09 �.09 �.13

8. Income — .11 .10 .02 .07

9. Rel. status — .02 �.06 .18�

10. TSL — �.26�� .12

11. Contact — �.17�

12. Violent=non —

Note: PRC¼positive religious coping; NRC¼ negative religious coping; TSL¼ time since loss; Contact¼ preloss frequency of contact with the

deceased; Rel. status¼ relationship status—in a romantic relationship or not; Violent=non¼ violent vs. nonviolent death.�p< .05. ��p< .01.

264 L. A. BURKE AND R. A. NEIMEYER

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members of the faith community in constructive waysregardless of the intensity of their distress. In contrast,those who suffer bereavement complication appear tobe at risk for spiritual distress.

We have consistently found (see also Burke et al.,2011) that CG predicts CSG both globally (i.e., usingNRC and Discontent total scores) and at an item-by-item level, even when correlated background variablesare held constant. In fact, in the present study, collectingdata on a larger, more diverse sample produced a great-er number of examples, and a more heterogeneousmodel of spiritual struggle. Specifically, in addition toreplicating previous findings (Burke et al., 2011), wefound that grievers who struggled with the loss of theirloved one also simultaneously struggled with feelingangry with or distant from God and from members oftheir church, felt punished by God for a lack of devo-tion, wondered whether God had abandoned them,

questioned their religious beliefs and faith, and endorsedthe notion that the devil made the death occur. How-ever, unlike Burke et al.’s (2011) sample, grievers inthe present study with high levels of longing and yearn-ing for their deceased loved one did not have high levelsof CSG. In light of these findings, further analyses ofthese constructs comparing differences between violentand nonviolent cohorts might illuminate nuances ingrievers’ experiences.

In relation to cause of death, our findings revealedthat this factor differentially predicted struggles withboth grief and faith. Not surprisingly, mourners whoseloved ones died violently reported the greatest difficultyaccommodating the loss emotionally and spiritually.Specifically, those persons whose loved ones had takentheir own lives, been murdered, or suffered a fatal acci-dent experienced significantly greater complicated griefthan did those bereaved by natural death. However,

TABLE 5

ANCOVA Posthoc Comparisons (Sidak) Showing That Cause of Death Differentially Predicted Complicated Grief and

Complicated Spiritual Grief in a Diverse Sample of Grievers (n¼150)

Type of death CG M (SD) NRC M (SD) Discontent M (SD)

Natural anticipated 45.61 (16.18)a 2.39 (3.65)c 1.21 (2.11)a

Natural sudden 54.71 (20.53)a 3.23 (2.98)ab 1.37 (2.17)a

Suicide 76.60 (28.75)c 4.40 (4.39)ab 3.20 (2.17)a

Homicide 73.15 (.03)b 5.05 (5.28)ab 1.35 (1.84)a

Accident 58.27 (19.11)abc 7.27 (7.27)b 2.70 (2.54)a

Note: a, b, c superscripts represent homogeneous subsets or statistically equivalent groups of means on respective

outcome measures. ANCOVA¼ analysis of covariance; CG¼ complicated grief; NRC¼negative religious coping;

Complicated Spiritual Grief¼NRC and Discontent item.

TABLE 4

Hierarchical Multiple Regressions Showing Association Between Complicated Grief Total Scores and Individual

Complicated Spiritual Grief Items in a Diverse Sample of Grievers (n¼150)

Overall F b Total R2 DR2

Item # NRC Itema

8 Wondered whether God had abandoned me 7.48��� .35��� .21 .10

9 Felt punished by God for my lack of devotion 7.96��� .32��� .22 .08

10 Wondered what I did for God to punish me 6.54��� .25�� .19 .05

11 Questioned God’s love for me 3.70�� .18� .12 .03

12 Wondered whether my church had abandoned me 3.64�� .20� .12 .03

13 Decided the devil made this happen 10.02��� .23�� .24 .04

14 Questioned the power of God 3.00�� .23�� .10 .04

Item # Discontent Itemb

18 Felt angry with or distant from God 8.39��� .25�� .10 .06

19 Felt angry with or distant from members of the church 7.63��� .28��� .10 .08

20 Questioned my religious beliefs and faith 7.48��� .35��� .05 .03

Item # Longing=Yearning Itemc

9 Felt punished by God for my lack of devotion 5.21��� .15þ .16 .02

10 Wondered what I did for God to punish me 5.07��� .14þ .15 .02

Note: NRC¼negative religious coping; Complicated Spiritual Grief¼NRC and Discontent items.aControlling for age, education, income, and violent=nonviolent loss.bControlling for age.cSee Inventory of Complicated Grief–Revised (ICG-R).þp� .05. �p� .05. ��p< .01. ���p< .001.

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no differences were found between types of violent deathlosses on measures of spiritual struggle, suggesting thatit may be their common elements, such as their sudden-ness, traumatic nature, or the role of human intention orinattention that can lead some believers to question theirfaith in light of the unpredictable, uncontrollablerandomness of life. Thus, future research would do wellto identify features of tragic losses that pose particularchallenges to people’s spiritual coping, particularlythose subject to modification in applied contexts.

Clinically, the present findings suggest that the needexists for spiritually sensitive clinicians and clergy towork together to develop informed and culturally app-ropriate interventions for spiritually inclined bereavedclients, and especially for those whose losses are sudden,unexpected, and violent. More work is also warranted inthe assessment of spiritual struggle in the specific contextof bereavement, inasmuch as the existential issues thatcan arise in the wake of a loved one’s death may differin kind as well as degree from those triggered by lesspermanent or pervasive life stressors or transitions.The refinement of both assessment and intervention islikely to benefit from systematic qualitative researchon the experience of spiritual struggle in bereavement,to yield a richer depiction of the distinctive themes thatdefine such mourners’ challenged beliefs, relationshipwith God, and connection to the faith community.A step in this direction has been taken by the companionstudy to the present one, reported by Burke and collea-gues (2014, this isssue).

Limitations

The current study is one of few exploring the relationbetween complicated bereavement and spiritual crisis.Strengths of our design include participant diversity interms of age, race, church affiliation, and mode of death,as well as reliance on well-validated measures of majorstudy variables. Furthermore, generalizability likely isenhanced because our data closely reflect the ethnicdemographics of the area in which the study wasconducted.

Nevertheless, some limitations to the study should beconsidered when interpreting our findings. First, theresearch design was limited because of its cross-sectionalnature. Unlike our previous longitudinal studies witha more distinctly defined sample (Burke et al., 2011;Neimeyer & Burke, 2011), the present single-assessmentdesign precludes inferences regarding causal directional-ity between CG and CSG, or even the prospectiveprediction of outcome. Our understanding likely wouldbe greater in relation to our primary constructs hadwe conducted assessments at two or more time points.Despite using psychometrically established measuresto assess both complicated grief and spiritual crisis, all

responses were self-reported, which might reflect a recallbias or social desirability confounds. Including interview-based assessments of complicated grief and behavioralindices of religious disruption (e.g., decreased churchattendance) would strengthen confidence in the presentfindings.

In conclusion, the present study adds to a growingliterature pointing to the phenomenon of spiritual crisisin the wake of bereavement, and its association withdeleterious psychological outcomes in which mournerscan struggle for prolonged periods with painful preoccu-pation with their loved one’s death and the seemingemptiness of their own lives. Moreover, it underscoresthe particular salience of such disruptions in theaftermath of violent death losses, even those suffereda number of years ago. We hope that the demonstrationof these relations in the present quantitative analysis ofa large and diverse sample of bereaved individuals willencourage other investigators to join us in exploringthe conjunction of psychological and spiritual issuesin the context of bereavement, so that insights intoboth might render religious and secular professionalsbetter able to understand and help those who seek helpfollowing loss.

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