6200wk 9 asgn

The Coping Assessment for Bereavement and Loss Experiences (CABLE): Development and initial validation

Anne Elizabeth Crunka, Laurie A. Burkeb, Robert A. Neimeyerb�, Edward H. Mike Robinson, IIIc, and Haiyan Baid

aGraduate School of Education and Human Development, Department of Counseling and Human Development, The George Washington University, Washington, District of Columbia, USA; bDepartment of Psychology, The University of Memphis, Memphis, Tennessee, USA; cDepartment of Child, Family, and Community Sciences, University of Central Florida, Orlando, Florida, USA; dDepartment of Learning Sciences & Educational Research, College of Community Innovation and Education, University of Central Florida, Orlando, Florida, USA

ABSTRACT The authors present the development and validation of the Coping Assessment for Bereavement and Loss Experiences (CABLE), the first instrument designed to assess a range of potentially constructive strategies for coping with grief following the death of a loved one. Exploratory and confirmatory factor analysis with an international sample of bereaved adults (N¼ 844) yielded a six-factor, 28-item structure. Use of this validated, clinically useful, self- report tool can inform clinicians and researchers in evaluating bereavement coping, and in developing interventions designed to increase the number and broaden the types of coping strategies used to facilitate healing following loss.

The loss of a loved one through death is a virtually inescapable part of the human experience and one that can elicit marked psychological and physical dis- tress for the survivor (Stroebe, Schut, & Boerner, 2017). However, not all bereaved individuals cope with loss in the same way (Galatzer-Levy, Huang, & Bonanno, 2018). Contrary to traditional bereavement models that describe grief as a linear and uniform process, contemporary research has revealed consider- able variation in the duration and intensity of grief reactions among bereaved individuals (Bonanno et al., 2002; Galatzer-Levy et al., 2018). For example, some mourners experience common reactions to grief, with grief symptoms that attenuate within one to two years following loss (Bonanno, Wortman, & Nesse, 2004), and most grievers (i.e., approximately 50%) respond to loss with resilience, demonstrating an ability to sus- tain reasonably stable and adaptive levels of function- ing in response to loss (Bonanno, 2004). However, 10–15% of the bereaved population experiences a pro- tracted, debilitating, sometimes life-threatening grief response known as complicated grief (CG; Shear et al., 2011), also known as prolonged grief disorder (Maciejewski, Maercker, Boelen, & Prigerson, 2016; Prigerson et al., 2009) or persistent complex

bereavement disorder (American Psychiatric Association, 2013; see Crunk, Burke, & Robinson, 2017, for a review of the literature).

One factor that might distinguish bereaved individu- als’ grief reactions is how they cope with their grief (Meichenbaum & Myers, 2016), or the “processes, strat- egies, or styles of managing the situation in which bereavement places the individual” (Stroebe & Schut, 2010, p. 274). Identifying the specific strategies mourn- ers use to cope with their grief is necessary to inform researchers and mental health professionals in develop- ing relevant interventions to support grievers following loss. However, one obstacle to understanding grief cop- ing has been the absence of bereavement-specific instruments designed to assess a range of potentially constructive strategies for coping with loss. As a result, researchers and clinicians have had few tools for identi- fying the coping strategies used by bereaved individuals to aid in developing personalized interventions, and instead have been limited to using nonspecific coping instruments. Therefore, in this article we propose a new instrument called the Coping Assessment for Bereavement and Loss Experiences (CABLE).

The CABLE is distinct from other coping instru- ments, such as the COPE (Carver, Scheier, &

CONTACT Anne Elizabeth Crunk [email protected] Graduate School of Education and Human Development, Department of Counseling and Human Development, The George Washington University, 2134 G Street NW, Washington, DC 20052, USA.�Director, Portland Institute for Loss and Transition. � 2019 Taylor & Francis Group, LLC

DEATH STUDIES 2021, VOL. 45, NO. 9, 677–691 https://doi.org/10.1080/07481187.2019.1676323

Weintraub, 1989) – a 60-item, nonspecific measure of coping with stressful life events – in that the CABLE is a brief assessment designed to measure coping fol- lowing the death of a loved one, in particular, rather than life stressors, in general. The CABLE also differs from bereavement distress instruments such as the Hogan Grief Reaction Checklist (Hogan, Daryl, Greenfield, & Schmidt, 2001) or the Inventory of Complicated Grief-Revised (Prigerson et al., 1995), in that it measures strategies for managing grief, rather than levels of grief distress. Furthermore, the CABLE is unique in its focus on coping strategies that are considered adaptive, providing practitioners with a tool for helping mourners identify potentially con- structive coping strategies that they might employ to cope with their grief. Importantly, we must note that it was not an aim of this study to examine associa- tions between individual strategies or subscales and bereavement outcomes; thus, we refer to these strat- egies as “potentially constructive” to differentiate them from strategies that are clinically contraindicated in grief treatment and from those that are known mal- adaptive coping strategies (e.g., drinking alcoholic bev- erages to cope; Høeg et al., 2017; or social isolation; Tofthagen, Kip, Witt, & McMillan, 2017), which we chose to exclude from the item pool because we hypothesized they would correlate highly with compli- cated grief. Nevertheless, the CABLE can help clini- cians and researchers to identify what mourners are currently doing to cope with their grief, shedding light on potentially useful clinical information such as what the bereaved individual values (e.g., spiritual support) or coping resources to which the individual has access (e.g., organized bereavement support groups), assisting clinicians in tailoring treatment to their clients’ values, preferences, and resources. To our knowledge, a brief, multidimensional, and well-validated measure of potentially adaptive, bereavement-specific coping strat- egies has not previously been developed and tested with a diverse sample of grievers.

Coping with grief

Coping has been defined as one’s “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding one’s resources” (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986, p. 993). Stroebe and Schut’s (1999, 2010) Dual Process Model (DPM) has been widely used to describe loss-ori- ented coping and restoration-oriented coping commonly used in adaptive grieving following death. The DPM

suggests that adaptive grief coping resembles the move- ment of a pendulum such that mourners naturally oscil- late between attending to their grief (i.e., loss orientation) and adjusting to life without the deceased (i.e., restoration orientation). Both the loss-oriented and restoration-oriented processes involve cognitive, behav- ioral, and emotional strategies that bereaved individuals employ to manage bereavement distress. For example, loss-oriented coping might include allowing oneself time to cry or to look at photos of the deceased, whereas restoration-oriented coping might include forming new relationships with others or taking on tasks that were previously carried out by the deceased (e.g., paying bills). Both types of coping theoretically are integral to a healthy bereavement process, such that preoccupation with either orientation rather than oscillation between the two can impede adaptive coping.

Stroebe, Folkman, Hansson, and Schut (2006) asserted that coping strategies can serve as a bereave- ment mediator, such that individual differences in coping might influence the mourner’s overall bereave- ment trajectory and lower grief distress. For example, Ryckebosch-Dayez, Zech, Mac Cord, and Taverne (2016) found that widowed persons who employed avoidance strategies (e.g., going outdoors, reading a novel) in response to loss-oriented stressors (e.g., loneliness as a result of their loss) reported a decrease in initial perceived distress. Other studies have made strides toward understanding bereavement outcomes in the context of prospective risk factors such as type of loss (e.g., violent or natural), gender, racial and eth- nic background, and specific coping mechanisms in isolation (e.g., spiritual coping). Although helpful in identifying who is at risk for bereavement distress, static risk factors are not amenable to modification in counseling, signaling a need for further investigation of predictors of bereavement outcomes that are modi- fiable by intervention, such as coping strategies (Burke & Neimeyer, 2013). Thus, this study sought to develop an instrument for assessing a diverse range of loss- and restoration-oriented strategies that grievers employ to cope with loss. Drawing on coping theories advanced by other researchers (Folkman et al., 1986; Meichenbaum, 2013; Stroebe & Schut, 1999, 2010), for this study we defined grief coping as:

the employment of potentially adaptive cognitive, behavioral, emotional, spiritual, and social strategies for managing the external and/or internal challenges associated with the bereavement processes of individual mourners.

The extant literature points to several coping domains that individuals tap into for support

678 A. E. CRUNK ET AL.

following bereavement and other highly distressing events. For example, Meichenbaum (2013) examined approaches for bolstering resilience following trauma and classified coping strategies into six general catego- ries, including physical, interpersonal, emotional, cog- nitive, behavioral, and spiritual coping. Furthermore, in a rare attempt to provide a comprehensive analysis of the particular strategies mourners use to cope with their grief, Asai et al. (2012) examined the coping strategies of Japanese spouses bereaved by natural causes (N¼ 821), yielding a three-factor structure of grief coping with their sample, which included: (a) dis- traction (e.g., engaging in physical activity), (b) continu- ing bonds (e.g., keeping possessions of the deceased nearby), and (c) social sharing/reconstruction (e.g., seek- ing emotional support from family members).

Other bereavement studies have examined the role of individual coping strategies, such as social support (e.g., Bottomley, Burke, & Neimeyer, 2015), spiritual coping (e.g., Burke & Neimeyer, 2014), meaning mak- ing (Neimeyer, 2016), and cognitive-behavioral strat- egies that influence coping with grief (Boelen, de Keijser, & Smid, 2015). Furthermore, the concept of maintaining a continuing bond with a deceased loved one has challenged earlier theories on how mourners adapt to loss, suggesting that successful adjustment to bereavement can include an ongoing attachment to the deceased (e.g., Field, 2008; Klass & Steffan, 2017) rather than the relinquishment of this relationship (e.g., Freud, 1917). In addition, other studies have examined the role of professional bereavement support and help- seeking behaviors (Currier, Neimeyer, & Berman, 2008; Drapeau, Cerel, & Moore, 2016), Internet-based serv- ices (e.g., online peer support, grief-focused chatroom discussions; e.g., Van der Houwen, Stroebe, Schut, Stroebe, & van den Bout, 2010), self-help (e.g., biblio- therapy; Dennis, 2012), and altruistic forms of coping (Wells, Hobfoll, & Lavin, 1997).

Although these coping strategies are among the most commonly examined in bereavement research, they represent only a handful of the potential ways a mourner might respond in order to manage bereave- ment stressors. Studies that examine individual coping strategies and their relation to bereavement outcomes are valuable in illuminating their role in helping griev- ers adapt to loss, yet there is a need for studies that investigate the influence of employing multiple coping strategies. Our intent with the CABLE was not to impose theoretical preconceptions on classes of coping activities, but rather to draw on many sources to reflect the myriad responses that stem from numerous

possible categories of coping (e.g., social support, spir- itual coping, seeking professional support).

Need for a bereavement-specific coping instrument

Studies on grief coping aim to evaluate strategies that bereaved individuals use to manage their grief. However, to date, much of this research has been lim- ited to using either unidimensional or nonspecific instruments that were designed to assess coping in the context of general life stressors rather than bereave- ment. We identified three exceptions: The Continuing Bonds Scale (CBS; Field, Gal-Oz, & Bonanno, 2003), the Dual Coping Inventory (DCI; Wijngaards-de-Meij, 2007), and the Inventory of Daily Widowed Life (IDWL; Caserta & Lund, 2007). However, these instruments are limited in their application, as the CBS measures only continuing bonds, the DCI was developed to assess coping in bereaved parents, and the IDWL was developed for bereaved spouses. Thus, prior to this study, we identified no existing instru- ments that assess diverse grief-specific coping strat- egies in heterogeneous samples of grievers.

Moreover, an instrument designed and validated to measure distinct grief-coping strategies with a diverse sample of bereaved individuals is necessary for develop- ing and evaluating interventions for bereaved individu- als. In fact, such a tool could be useful for grievers who benefit from self-monitoring and self-management of their grief. Unlike nonspecific measures of coping, the CABLE captures bereavement-specific strategies such as maintaining an ongoing symbolic relationship with the deceased or a “continuing bond” (Klass & Steffan, 2017), and the inclusion of items such as I attended grief therapy sessions from a mental health professional; and I set aside time to talk with my Higher Power about my grief. In contrast, nonspecific coping measures include generally phrased items (e.g., the COPE [Carver et al., 1989], I talk to someone to find out more about the situation; or the Coping Inventory for Stressful Situations [CISS; Cosway, Endler, Sadler, & Deary, 2000], [I] Come up with several different solutions to the problem) or items that would be inappropriate or irrelevant for grievers (e.g., the Ways of Coping (Revised) Questionnaire [WC-R; Folkman & Lazarus, 1985], [I] Tried to get the person responsible to change his or her mind).

With the present instrument, we therefore aimed to develop a more comprehensive assessment of naturally occurring, potentially constructive factors that under- lie grief coping, beyond the more generic measures of

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coping provided in existing scales. The present study outlines the development of the CABLE and examines its psychometric properties with an international sam- ple of bereaved adults, evaluating its (a) factor structure using exploratory factor analysis and confirmatory factor analysis, (b) convergent validity with similar constructs, and (c) internal consistency reliability of the total scale and the individual subscales.

Method

Phase 1: Item generation

We developed the CABLE using empirically supported scale development procedures (Crocker & Algina, 2008; DeVellis, 2012, 2017; Dimitrov, 2012). The initial item pool was adapted from Meichenbaum and Myers’ (2016) 55-item checklist of grief coping strategies, which we modified extensively following a review of the litera- ture on grief coping, incorporating items suggested by grief therapy and research experts, and piloting the scale with two samples of bereaved adults using a focus-group (Plummer-D’Amato, 2008) and protocol analysis – a procedure in which participants are instructed to “think aloud” about their process of completing the task (Collins, 2003). Following the University’s Institutional Review Board’s (IRB) approval, we recruited Phase 1 participants to understand better the coping strategies of grievers by canvasing them with regard to (a) the clarity and readability of item wording, (b) item relevance to potentially constructive grief coping strategies, (c) the level of ease in completing the scale, and (d) their sug- gestions of additional items.

We first conducted a focus group session with bereaved adults (n¼ 7) who we recruited from a co- investigator’s private practice in the northwest region of the United States. Although we did not formally assess for bereavement distress, focus group partici- pants comprised a clinical sample with a range of grief severity. We refined the initial item pool from focus group members’ feedback. We then conducted indi- vidual protocol analysis interviews with a second non- clinical sample of bereaved master’s-level counseling students (n¼ 5) from a U.S. south-eastern university, using concurrent verbalization (Ericsson & Simon, 1980), in which the participant attended to the task of completing the CABLE and simultaneously voiced his or her cognitive processes related to doing so. Again, we revised the CABLE to reflect participants’ responses from protocol analysis interviews, resulting in a refined, testable scale. Phase 1 development pro- cedures yielded 89 candidate items, the majority of which were adapted from Meichenbaum and Myers’

(2016) checklist of grief coping strategies, and approximately 30 additional items that were gleaned from Phase 1 qualitative analyses, review of the grief coping literature, and items suggested by experts in grief therapy and bereavement research.

Phase 2: Item selection, validation, and examination of reliability

Participant recruitment We recruited Phase 2 participants using Amazon’s Mechanical Turk (MTurk; Buhrmester, Kwang, & Gosling, 2011), an online crowdsourcing marketplace. Participants were provided a description of the task, eligibility criteria, anticipated completion time, task instructions, and compensation rate. Compensation was $0.50 for participants who completed the study, which is a comparable, average rate for similar MTurk tasks. Data were collected from a diverse international sample (e.g., nationality, race and ethnicity, age, gen- der, type of loss, and relationship to the deceased) of bereaved adults, who met the following inclusion cri- teria: (a) 18 years old or older, (b) bereaved within the past five years, and (c) able to read English fluently (see Table 1 for participant demographics and loss- related information). Cleaning and vetting of the data yielded a sample size of 844 participants with com- plete and usable data.

Data collection Participation in this study involved completion of the CABLE, the BriefCOPE (Carver, 1997), and a back- ground questionnaire for capturing demographic and loss-related information about the griever and his/her deceased loved one. All participants accessed the study through the MTurk user portal and interested partici- pants were directed to Qualtrics for all data collection for this study. To assess the factor structure, validity, and reliability of the scale, we administered the CABLE with a large group of adults bereaved within the past five years. Three validation or “attention check” items were used to detect haphazard responses (e.g., I painted my entire house just to keep busy), flag- ging participants who endorsed nearly every day or daily. Data cleaning included removing cases in which a participant provided inappropriate responses to two out of the three validation items, because doing so indicated high likelihood of random responding (e.g., endorsing all items with daily or never). We examined correlations between the CABLE and the BriefCOPE to assess the convergent validity of the CABLE and hypothesized a medium effect size.

680 A. E. CRUNK ET AL.

Table 1. Participant demographic and loss-related information for EFA and CFA samples. EFA Sample (n¼ 422) CFA Sample (n¼ 422)

Age (M¼ 34.6 years; SD¼ 11.5) Total (n) % Age (M¼ 34.3 years; SD¼ 10.9) Total (n) % 18–24 66 15.6 18–24 67 15.9 25–34 199 47.2 25–34 190 45.0 35–44 83 19.7 35–44 96 22.7 45–54 41 9.7 45–54 40 9.5 55–64 23 5.5 55–64 18 4.3 65þ 10 2.4 65þ 11 2.6

Gender Gender Female 262 62.1 Female 249 59.0 Male 159 37.7 Male 171 40.5 Transgender 0 0 Transgender 1 <1 Other 1 <1 Other 1 <1

Ethnicity (if American) Ethnicity (if American) African American 32 7.6 African American 31 7.3 Asian American 98 23.2 Asian American 77 18.2 Hispanic/Latino/Latina 35 8.3 Hispanic/Latino/Latina 33 7.8 Native American 18 4.3 Native American 11 2.6 White 237 56.2 White 259 61.4 Other 24 5.7 Other 29 6.9

Continent of Origin Continent of Origin Asia 100 23.7 Asia 83 19.7 Africa 10 2.4 Africa 7 1.7 Australia/Oceania 3 <1 Australia/Oceania 2 <1 Europe 23 5.5 Europe 34 8.1 North America 274 64.9 North America 279 66.1 South America 11 2.6 South America 16 3.8 Other response 1 <1 Other response 1 <1

Employment Status Employment Status Employed full-time 230 54.5 Employed full-time 244 57.8 Employed part-time 82 19.4 Employed part-time 68 16.1 ot currently employed, looking 28 6.6 Not currently employed, looking 32 7.6 Not currently employed, not looking 27 6.4 Not currently employed, not looking 25 5.9 Full-time student 26 6.2 Full-time student 24 5.7 Other (e.g., retired) 29 6.9 Other (e.g., retired) 29 6.9

Educational Level (Years of education) Educational Level (Years of education) Primary/elementary school (0–6) 1 <1 Primary/elementary school (0–6) 1 <1 Some high school (<12) 7 1.7 Some high school (<12) 2 <1 High school graduate or GED (12) 43 10.2 High school graduate or GED (12) 48 11.4 Some university or trade school 109 25.8 Some university or trade school 117 27.7 Completion of university or trade school 152 36.0 Completion of university or trade school 145 34.4 Some post-graduate or

professional school 37 8.8 Some post-graduate or

professional school 39 9.2

Completed post-graduate or professional degree

73 17.3 Completed post-graduate or professional degree

70 16.6

Household Income Household Income Less than $10,000 65 15.4 Less than $10,000 61 14.5 $10,000 to less than $20,000 44 10.4 $10,000 to less than $20,000 61 14.5 $20,000 to less than $30,000 69 16.4 $20,000 to less than $30,000 61 14.5 $30,000 to less than $40,000 53 12.6 $30,000 to less than $40,000 59 14.0 $40,000 to less than $50,000 45 10.7 $40,000 to less than $50,000 46 10.9 $50,000 to less than $75,000 86 20.4 $50,000 to less than $75,000 63 14.9 $75,000 to less than $100,000 39 9.2 $75,000 to less than $100,000 36 8.5 $100,000 to less than $150,000 16 3.8 $100,000 to less than $150,000 25 5.9 $150,000 or more 5 1.2 $150,000 or more 10 2.4

Currently Receiving Mental Health Services Currently Receiving Mental Health Services Yes 44 10.4 Yes 48 11.4 No 372 88.2 No 357 84.6 Prefer not to respond 6 1.4 Prefer not to respond 17 4.0

Participant Relationship to the Deceased Participant Relationship to the Deceased Aunt or uncle 16 3.8 Aunt or uncle 21 5.0 Cousin 12 2.8 Cousin 14 3.3 Daughter or son 88 20.9 Daughter or son 84 19.9 Friend 39 9.2 Friend 30 7.1 Granddaughter or grandson 78 18.5 Granddaughter or grandson 85 20.1 Grandparent 51 12.1 Grandparent 55 13.0 Niece or nephew 17 4.1 Niece or nephew 17 4.0 Parent 45 10.7 Parent 33 7.8 Intimate partner/fianc�e(e) 29 6.9 Intimate partner/fianc�e(e) 27 6.4 Sibling 14 3.3 Sibling 28 6.6 Spouse 14 3.3 Spouse 10 2.4 Other (e.g., co-worker) 19 4.5 Other (e.g., co-worker) 18 4.3

(Continued)

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Instruments

Coping Assessment for Bereavement and Loss Experiences (CABLE) The CABLE was developed to identify strategies that bereaved individuals use to cope with grief. The initial item pool included 89 items, each of which was rated on a 5-point verbal frequency scale (Scarborough, 2005) to indicate the frequency with which partici- pants used each strategy within a two-week timeframe, ranging from 0 (Never) to 4 (Daily), as well as a neu- tral response option (N/A – This does not apply to me or to my loss; Crocker & Algina, 2008; DeVellis, 2017) for coping strategies that are irrelevant to some partic- ipants (e.g., items that refer to spiritual or religious coping). Sample items include: I identified supportive individuals to turn to when I am experiencing feelings of grief; and I took steps to regain my sense of hope, such as creating goals for the future. The scale also includes four open-response items for participants to write in grief coping strategies they have used that were not on the scale, three open-response items for participants to indicate which strategies were particu- larly helpful for them, and one open-response item for participants to share anything else they wanted us to know about their grief coping. We recommend the following two scoring options: (a) calculating the aver- age of each subscale (i.e., summing the items of a sub- scale and dividing by the total number of items on that subscale) to examine coping frequency between each coping domain, and/or (b) assessing coping fre- quency of strategies at the individual-item level.

BriefCOPE The BriefCOPE (Carver, 1997) is a 28-item abbrevi- ated version of the original 60-item scale (i.e., the COPE; Carver et al., 1989) that measures the fre- quency of engaging in behavioral and cognitive strat- egies for coping with general life stressors. The BriefCOPE uses a 4-point Likert-type scale with response options ranging from 0 (I haven’t been doing this at all) to 3 (I’ve been doing this a lot). Sample

items include, I’ve been concentrating my efforts on doing something about the situation I’m in, and, I’ve been accepting the reality of the fact that it has hap- pened. The BriefCOPE demonstrated acceptable internal reliability on each of the seven subscales (a coefficients for the subscales ranging from .50 to .90) in a community sample of participants who had been critically affected by Hurricane Andrew (Carver, 1997). In the present study, the BriefCOPE showed good internal consistency reliability, with Cronbach’s alphas of .83 and .80 for the exploratory factor ana- lysis (EFA) and confirmatory factor analysis (CFA) subsamples, respectively.

Data analysis

Data cleaning and exploratory factor analyses were conducted using SPSS (Mac and Windows Version 24.0). Cleaning and vetting of the data yielded a final sample size of 844 participants. Of the 1,542 individuals who entered the Qualtrics survey, we withdrew partici- pants who previewed the survey but completed 0% of it (n¼ 35), and cases with extensive missing data on the secondary instruments not included in the present study; n¼ 317). Only participants who had completed 100% of the instruments used in the present study (i.e., the CABLE, the BriefCOPE, and the demographics questionnaire) were included in the final sample.

Additionally, participants were excluded from anal- yses if they did not accept the informed consent form (n¼ 59), did not meet the years since loss criteria (n¼ 53), or indicated that they lost a pet rather than a human (n¼ 2). Data from participants who pro- vided irregular responses (i.e., random responding) to two out of the three validation items (n¼ 151) were also excluded. We combined participant data from the response option N/A – This does not apply to me or to my loss with the Never response option to create one variable conveying that participants did not engage in this particular strategy.

Table 1. Continued. EFA Sample (n¼ 422) CFA Sample (n¼ 422)

Cause of Death Cause of Death Natural anticipated 179 42.4 Natural anticipated 182 43.1 Natural sudden 151 35.8 Natural sudden 135 32.0 Accident 50 11.8 Accident 50 11.8 Violent or traumatic (e.g., homicide,

suicide, terrorism, natural disaster) 26 6.2 Violent or traumatic (e.g., homicide,

suicide, terrorism, natural disaster) 34 8.1

Other (e.g., medical malpractice) 16 3.8 Other (e.g., medical malpractice) 22 5.2 Years Since Loss (M¼ 2.2 years; SD¼ 1.7) Years Since Loss (M¼ 2.0 years; SD¼ 1.7)

682 A. E. CRUNK ET AL.

Tests of normality indicated that the data were nor- mally distributed, with a Kolmogorov-Smirnov value of p ¼ .200 and a Shapiro-Wilk value of p ¼ .736. However, an inspection of the histograms of each item revealed several items that were not normally distributed (Pallant, 2013). We then generated box- plots for each item and removed cases with univariate outliers (n¼ 81). Bartlett’s test of sphericity yielded a significant value of 2 (3916) ¼ 17794.937 (p < .001) and the Kaiser-Meyer-Olkin (KMO; Kaiser, 1970, 1974) measure of sampling adequacy produced a value of .913 for the original 89-item scale, indicating that the data were appropriate for factor analysis.

Using SPSS, we randomly split the total sample into two subsamples for conducting exploratory factor ana- lysis (EFA; n¼ 422) and confirmatory factor analysis (CFA; n¼ 422), yielding a participant-to-item ratio (N:p; Hair, Black, Babin, Anderson, & Tatham, 2006) for EFA of approximately 5:1 (i.e., 5 participants for each of the initial 89 items). This is a moderate ratio of participants per item (Hair, Black, Babin, & Anderson, 2010), with samples of greater than 300 participants deemed appro- priate for EFA (Comrey & Lee, 1992). We found no sig- nificant proportion differences in demographic variables between EFA and CFA subsamples. We used the princi- pal factor analysis extraction method, which analyzes only the common variance (as opposed to both common

and unique variance, as in principal components ana- lysis) and is recommended when the purpose of EFA is to uncover latent factors in the data (Mvududu & Sink, 2013). In addition, we used an oblique (i.e., direct obli- min) rotation method, which assumes that factors are correlated (Mvududu & Sink, 2013). Following evalu- ation of individual items, the final step included remov- ing items that performed poorly or did not contribute to the overall alpha level of the scale, with the goal of obtaining a parsimonious final scale that generates appropriate reliability and validity scores (Crocker & Algina, 2008; DeVellis, 2017). We removed CABLE items that failed to meet the following pre-determined criteria for item retention using exploratory factor analysis (Field, 2013; Hair et al., 2006; Mvududu & Sink, 2013; Pallant, 2013): (a) a value of 0.5 or greater measurement sample accuracy (MSA) for each item, (b) a value of 0.2 or greater disparity between factor loadings, (c) items with communalities greater than .30, (d) the Guttman- Kaiser criterion of eigenvalues greater than 1.00, (e) fac- tor loadings with values of 0.30 or greater, and (f) factors with three or more items (Costello & Osborne, 2005). We also examined the scree plot to cross-validate factor selection (see Figure 1). The final version of the CABLE consists of 28 items that loaded onto six factors.

Once we obtained an optimal item pool and factor structure through EFA, we used the second subsample

Figure 1. Scree plot for exploratory factor analysis for 28-item CABLE.

DEATH STUDIES 683

to conduct CFA for preliminary cross-validation of the exploratory analyses. CFA was performed using SPSS Amos (Mac and Windows Version 24.0). We evaluated the CFA model using several fit indices, including the chi-square goodness-of-fit test, the Root Mean Squared Error of Approximation (RMSEA) index, as well as the Root Mean Square Residual (RMR), Normed Fit (NFI), and Comparative Fit (CFI) indices (Mvududu & Sink, 2013). We then replicated the exploratory and con- firmatory analyses with parallel analysis (Horn, 1965) using macros for SPSS (O’Connor, 2000).

Following EFA, CFA, and parallel analysis, we assessed the convergent validity of the CABLE in the total sample. Specifically, we examined correlations between the CABLE and the BriefCOPE (Carver, 1997) to assess convergent validity. We also computed Cronbach’s alphas to assess the internal consistency reliability of the total scale, as well as for each of the individual factors extracted in the factor analysis.

Results

Exploratory factor analysis

The final EFA model yielded a six-factor, 28-item fac- tor structure. Although much shorter compared with the original 89-item pool, the final, parsimonious scale

represents only the best performing items per our item retention criteria. Bartlett’s test of sphericity remained favorable, with a significant value of v2 (378) ¼ 4617.630 (p < .001) and a KMO value of .883. Each retained factor had eigenvalues greater than 1.00. Although all extracted communalities met our criteria of .30 or higher, only eight items yielded com- munalities over the recommended value of .50 (Kline, 1994). Factor loadings, descriptive statistics, and factor correlations are presented in Tables 2–4, respectively. EFA resulted in six factors that we labeled based on content of the items: (1) Help-Seeking, (2) Positive Outlook, (3) Spiritual Support, (4) Continuing Bonds, (5) Compassionate Outreach, and (6) Social Support. Of note, the Spiritual Support and Social Support fac- tors had negative loadings across all items, whereas items on the other factors loaded consistently positively. Moreover, these same factors correlated negatively with the other factors.

Confirmatory factor analysis

Using the factors identified by the EFA model, we loaded the identified items on the six factors in the CFA model to further study the construct validity using the CFA subsample of 422 participants.

Table 2. Factor loadings for exploratory factor analysis of the CABLE.

Item

Factor

1 2 3 4 5 6

10. I read self-help books about the grieving process or coping with grief. .783 .000 �.067 �.035 .001 .000 9. I attended grief therapy sessions from a mental health professional. .730�.058 .016 �.001 .095 .083 8. I sought help from organized bereavement support groups. .713�.032 �.044 .013 �.025 .006 12. I visited websites that focus on the grieving process. .690�.053 .005 .047 .039 .026 11. I consulted professional resources (for example, Internet websites) to help me cope. .645 .018 .048 .072 �.020 .018 19. I made notes of how well I am doing. .580 .115 �.008 �.064 �.080 �.132 18. I posted reminders of how to cope during difficult times in visible locations to look at when I am struggling. .532�.002 �.068 .103 �.036 �.145 16. I focused on the things I am doing to get better, rather than on how bad things are. �.049 .661 .012 .012 .017 .006 17. I reminded myself of my strengths. �.067 .636 .003 .083 .090 �.048 20. I took steps to regain my sense of hope, such as creating goals for the future. �.014 .530�.059 .017 �.049 �.235 13. I reminded myself of the things I am thankful for. .017 .525�.106 �.012 .294 .099 21. I took steps toward a "new me" by coming up with some new goals or plans for my life. .178 .444�.059 .006 �.124 �.143 6. I turned to my spirituality or religion for comfort (for example, prayer or scripture reading). �.059 �.039 �.929�.024 .043 .003 24. I turned to my spirituality in order to experience hopefulness or peace. .015 �.006 �.893�.041 .032 .060 25. I set aside time to talk to God or my Higher Power about my grief. �.088 .022 �.731 .112 �.065 �.017 9. I attended a meeting or service related to my faith (for example, synagogue or church service). .205 .003 �.619�.018 �.009 �.072 22. I reviewed photos or videos of my loved one. .033 .025 .025 .670 .010 .022 14. I talked to my loved one in my mind or out loud. �.034 �.019 �.042 .634�.026 .008 23. I sought comfort in a keepsake or object that reminds me of my loved one. �.016 �.070 .021 .625 .167 �.039 15. I regularly set aside time by myself to express my grief and to remember my loved one. .057 .199 �.097 .552�.148 .078 28. I did things or went places that once held special meaning for my loved one and me. .173 �.049 �.026 .514 .014 �.189 3. I told someone how much I love or care for them. �.036 �.091 .010 .022 .729�.150 5. I cared for or nurtured others. .037 .210 �.015 .030 .546�.028 4. I engaged in an act of kindness toward someone. .074 .222 .002 .104 .477�.064 1. I reached out to others for comfort and companionship. �.088 .015 .008 .001 .190 �.689 27. I turned to others for positive feedback or praise. .043 .043 �.065 .009 .043 �.638 26. I looked for companionship by exploring new friendships. .183 .165 �.005 .106 �.146 �.419 2. I identified supportive individuals to turn to when I am experiencing feelings of grief. .171 .049 �.040 .190 .125 �.303

Note. Item numbers represent the final numbering system represented on the CABLE. Boldface values indicate items with a factor loading of .3 or higher. Factor 1: Help-Seeking; Factor 2: Positive Outlook; Factor 3: Spiritual Support; Factor 4: Continuing Bonds; Factor 5: Compassionate Outreach; Factor 6: Social Support.

684 A. E. CRUNK ET AL.

Specifically, we assessed a model with the following six latent factors, measured with the best items for each respective factor established previously in the exploratory model: (1) Help-Seeking, measured with seven items; (1) Positive Outlook, measured with five items; (3) Spiritual Support, measured with four items; (4) Continuing Bonds, measured with five items; (5) Compassionate Outreach, measured with three items; and (6) Social Support, measured with four items. The six-factor model demonstrated reason- ably good model fit after model modification, v2 (322)¼ 769.224, p < .001; RMR ¼ .087; NFI ¼ .831; CFI ¼ .893; RMSEA ¼ .057, 90% confidence interval (CI) ¼ .052–.063). Although chi-square fit indices should be nonsignificant (p > .05), significant chi-square is common with large samples and data from Likert scales. CFA supported a six-factor, 28- item scale, with each item loading above .40. Figure 2 displays the standardized factor loadings from the

CFA for the six-factor model tested in the CFA sam- ple. Contrary to the six-factor solution supported by EFA and CFA, our replication with parallel analysis suggested only a two-component solution, with sig- nificant raw data eigenvalues of 1.93 for the first com- ponent (i.e., Help-Seeking) and .34 for the second component (i.e., Positive Outlook). We chose to retain the six factors derived from EFA and confirmed in CFA in order to preserve the content validity of the CABLE; however, continued refinement and validation of the scale is warranted, and the exploratory and confirmatory findings should be interpreted with cau- tion until they can be tested with a different sample.

Internal consistency reliability

The CABLE demonstrated good internal consistency reliability among the 28 items comprising the total CABLE (a ¼ .89 and a ¼ .88 for EFA and CFA, respectively). Acceptable internal consistency reliability was found among each of the six factors in the EFA and CFA subsamples, respectively: (a) Help-Seeking (a ¼ .86, a ¼ .83), (b) Positive Outlook (a ¼ .76, a ¼ .76), (c) Spiritual Support (a ¼ .87, a ¼ .86), (d) Continuing Bonds (a ¼ .77, a ¼ .71), (e) Compassionate Outreach (a ¼ .70, a ¼ .65), and (f) Social Support (a ¼ .72, a ¼ .72). Analyses of the measure of convergent validity with the EFA and CFA subsamples revealed good internal consistency reliabil- ity for the BriefCOPE (a ¼ .83 and .80, respectively).

Table 3. CABLE descriptive statistics. Scores

Item Factor M SD

10. I read self-help books about the grieving process or coping with grief. 1 0.63 1.00 9. I attended grief therapy sessions from a mental health professional. 1 0.38 0.77 8. I sought help from organized bereavement support groups. 1 0.46 0.91 12. I visited websites that focus on the grieving process. 1 0.67 1.03 11. I consulted professional resources (for example, Internet websites) to help me cope. 1 0.82 1.07 19. I made notes of how well I am doing. 1 0.58 1.04 18. I posted reminders of how to cope during difficult times in visible locations to look at when I am struggling. 1 0.63 1.01 16. I focused on the things I am doing to get better, rather than on how bad things are. 2 2.23 1.20 17. I reminded myself of my strengths. 2 2.10 1.19 20. I took steps to regain my sense of hope, such as creating goals for the future. 2 1.84 1.19 13. I reminded myself of the things I am thankful for. 2 2.57 1.13 21. I took steps toward a "new me" by coming up with some new goals or plans for my life. 2 1.58 1.17 6. I turned to my spirituality or religion for comfort (for example, prayer or scripture reading). 3 1.72 1.53 24. I turned to my spirituality in order to experience hopefulness or peace. 3 1.78 1.50 25. I set aside time to talk to God or my Higher Power about my grief. 3 1.57 1.47 7. I attended a meeting or service related to my faith (for example, synagogue or church service). 3 1.00 1.18 22. I reviewed photos or videos of my loved one. 4 1.89 1.12 14. I talked to my loved one in my mind or out loud. 4 1.73 1.25 23. I sought comfort in a keepsake or object that reminds me of my loved one. 4 1.69 1.30 15. I regularly set aside time by myself to express my grief and to remember my loved one. 4 1.63 1.23 28. I did things or went places that once held special meaning for my loved one and me. 4 1.13 1.06 3. I told someone how much I love or care for them. 5 2.52 1.28 5. I cared for or nurtured others. 5 2.27 1.29 4. I engaged in an act of kindness toward someone. 5 2.14 1.07 1. I reached out to others for comfort and companionship. 6 1.67 1.15 27. I turned to others for positive feedback or praise. 6 1.46 1.18 26. I looked for companionship by exploring new friendships. 6 1.15 1.14 2. I identified supportive individuals to turn to when I am experiencing feelings of grief. 6 1.34 1.13

Table 4. Factor correlation matrix. 1 2 3 4 5 6

1 1.000 2 .172 1.000 3 �.315 �.338 1.000 4 .434 .300 �.317 1.000 5 �.060 .229 �.004 .185 1.000 6 �.369 �.399 .200 �.339 �.232 1.000

Note. Factor 1: Help-Seeking; Factor 2: Positive Outlook; Factor 3: Spiritual Support; Factor 4: Continuing Bonds; Factor 5: Compassionate Outreach; Factor 6: Social Support.

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Convergent validity

Items loading on each factor of the CABLE were summed to examine how the items perform as subscales. To account for the two negatively-loading subscales, we reverse-coded these subscales in order to calculate a total CABLE score. Correlations between the total CABLE, CABLE subscales, and subscales of the BriefCOPE (Carver, 1997) that measure adaptive coping strategies were significantly correlated in the

expected direction. Specifically, higher total scores on

the CABLE were associated with higher total scores

on the adaptive coping subscales of the BriefCOPE in

the EFA and CFA subsamples, respectively (r ¼ .323,

p < .001; r ¼ .216, p < .001). We also examined correlations between factors of

the CABLE that reflect conceptually similar factors with the BriefCOPE (e.g., CABLE Spiritual Support and BriefCOPE Religion), with the exception of two CABLE

Figure 2. Six-factor confirmatory factor analysis for the 28-item CABLE.

686 A. E. CRUNK ET AL.

factors (i.e., CABLE Continuing Bonds and CABLE Compassionate Outreach) that are not conceptually consistent with the BriefCOPE. Our analyses yielded the following significant, positive correlations in both the EFA and CFA subsamples, respectively: (a) CABLE Help-Seeking and BriefCOPE Using Emotional Support and Using Instrumental Support (combined subscales; r ¼ .278, p < .001, r ¼ .272, p < .001), (b) CABLE Positive Outlook and BriefCOPE Positive Reframing (r ¼ .531, p < .001, r ¼ .378, p < .001), (c) CABLE Spiritual Support and BriefCOPE Religion (r ¼ .811, p < .001, r ¼ .799, p < .001), and (d) CABLE Social Support and BriefCOPE Using Emotional Support and Using Instrumental Support (combined subscales; r ¼ .505, p < .001, r ¼ .547, p < .001).

Discussion

Our goal in this study was to develop a bereavement- specific measure of coping entitled the Coping Assessment for Bereavement and Loss Experiences (CABLE), and to evaluate its psychometric properties with an international sample of bereaved adults. This resulted in a 28-item instrument with six subscales: (1) Help-Seeking, (2) Positive Outlook, (3) Spiritual Support, (4) Continuing Bonds, (5) Compassionate Outreach, and (6) Social Support. Confirmatory factor analysis for item selection supported this six-factor model of potentially constructive grief coping. Overall, the CABLE demonstrated reasonably good psychomet- ric properties in terms of internal consistency reliabil- ity of the individual factors and with the total CABLE, as well as convergent validity with the BriefCOPE (Carver, 1997). Compared to existing coping scales, the CABLE was designed as an instrument specifically for grievers, including bereavement-specific constructs (e.g., continuing bonds) and phrasing of items (e.g., I read self-help books about the grieving process or cop- ing with grief), and tested exclusively on a sample of bereaved individuals.

Consistent with the bereavement coping literature depicting an array of potential coping domains (Asai et al., 2010; Meichenbaum & Myers, 2016), the CABLE supported a multidimensional factor structure of grief coping, comprising emotional, cognitive, behavioral, spiritual, and social strategies in a heter- ogenous sample of adult grievers. The CABLE also was compatible with Stroebe and Schut’s (1999, 2010) Dual Process Model, with the inclusion of loss- oriented items (e.g., I regularly set aside time by myself to express my grief and to remember my loved one),

and restoration-oriented statements (e.g., I took steps to regain my sense of hope, such as creating goals for the future). Our findings revealed that mourners in our sample who scored highly on the CABLE likewise had moderately high scores on the BriefCOPE (Carver, 1997), suggesting its merit as a coping assess- ment for use with bereaved individuals specifically.

Although the CABLE depicts coping strategies that have been shown to aid grievers in adapting to loss, the literature simultaneously reveals that certain forms of coping can act as double-edged swords, proving to be helpful for some grievers, yet associated with dele- terious outcomes for others. For example, although religion and spirituality often serve as a means of adaptive coping, not all spiritually inclined grievers find comfort in their faith following loss. In fact, some grievers experience a rupture in their relation- ship with God and/or their spiritual community, a phenomenon known as complicated spiritual grief (Burke & Neimeyer, 2014). Use of social support to cope with grief presents a similar paradox, with stud- ies indicating that social support can serve as a pro- tective factor against poor bereavement outcome in some cases (Bottomley et al., 2015), but can exacer- bate grief symptoms in others (Burke, Neimeyer, & McDevitt-Murphy, 2010). Thus, clinicians advisably could use the CABLE to identify which strategies bereaved clients are using to cope with their grief, and as a tool for stimulating meaningful discussions about the productiveness of the client’s endorsed strategies. Our finding that the Social Support and Spiritual Support factors correlated negatively with other factors could suggest that they are negatively associated with bereavement outcomes.

Further fine-grained and longitudinal investigation also is necessary to examine how coping changes over time and whether there are optimal patterns of coping frequency, or if engaging in particular clusters or combinations of coping strategies is associated with more resilient bereavement outcomes. For example, it could well be that mourners in greater distress will turn to certain forms of coping early in bereavement (as reflected in a positive correlation of a given coping strategy with contemporaneous grief symptom- atology), whereas the practice of these same strategies might produce a reduction in symptomatology over time (as reflected in an inverse correlation of earlier reliance on this strategy with subsequent distress). Importantly, we wish to emphasize that this study does not elucidate the extent to which individual strategies and subscales of the CABLE are associated with levels of bereavement distress. Thus, at this stage

DEATH STUDIES 687

of validation, we advise clinicians and researchers against using the CABLE to predict key outcomes, such as level of bereavement distress or treatment effi- cacy. Clearly assessing the long-term adaptiveness of any given coping strategy will require longitudinal research. Subsequent research is also warranted to understand factors that mediate and/or moderate the relation between coping and bereavement outcomes, such as demographic characteristics (e.g., gender, race, nationality), bereavement-related contextual factors (e.g., traumatic vs. natural death loss), and disposi- tions of the griever (e.g., attachment style, resilience, inclination toward meaning making).

Our careful adherence to item retention guidelines necessitated removal of salient factors that are repre- sented in the bereavement literature. For example, consistent with prior studies suggesting that it can be helpful for grievers to take respite from grief (e.g., Stroebe & Schut, 2010), the CABLE’s initial item pool included items such as hobbies, entertainment, and physical activity; however, such items did not perform well in the present sample. Items that performed poorly reflected a thematic focus on meaning-making (e.g., I think about what I received from the deceased and the legacy to be fulfilled), self-care (e.g., I maintain self-care practices, such as personal hygiene, medical care, healthy nutrition, and regular sleep), recreational activities and hobbies (e.g., I participate in activities that have meaning and keep me occupied, such as work or hobbies), emotion regulation (e.g., I engage in meditation techniques such as breathing exercises or coping self-statements to regulate my strong negative emotions), and cognitive-behavioral strategies (e.g., I examine the thoughts that fuel my belief that things will never get better). Although prioritizing such guidelines sometimes jeopardizes the merit of certain measurement properties (e.g., content validity), we adhered to them in deference to obtaining a psycho- metrically sound scale (Loevinger, 1957). Thus, future research will involve the development and testing of an expanded version of the CABLE to include a broader scope of potentially constructive coping strat- egies. However, the present results suggest that the CABLE in its current preliminary form provides a promising multidimensional measure of coping with grief, and its use in future studies could yield clearer insights into the form and function of several com- mon responses in which mourners engage to mitigate and surmount the unique stressors of bereavement.

The current investigation represents a rare attempt to develop a multidimensional assessment tool for measuring grief-specific coping strategies. The

development of the CABLE was informed by both qualitative methods and relevant literature, providing a solid foundation for subsequent validation of the instrument (Creswell, 2014). Our use of expert review, a focus group, and protocol analysis strengthened both Phase 1 and the investigation overall. Strengths of Phase 2 included collecting data from a large, inter- national sample and ensuring participant diversity with respect to race/ethnicity, nationality, age, gender, type of loss, and kinship relationship to the deceased. However, even though participants reported the loss of a variety of types of relationships and had a wide range of incomes, our sample predominantly included North American Caucasian females who were younger (i.e., <45 years old), employed full-time, and were not receiving mental health services following a nonviolent death loss.

Study limitations

Notwithstanding the promising findings of the initial validation study, there are limitations that warrant consideration. For instance, although prior research supports MTurk’s viability as a data collection tool (Buhrmester et al., 2011), using additional, more traditional recruitment strategies (e.g., from private practices, hospices, religious institutions) and adminis- tration formats (e.g., paper-and-pencil, e-mail) would have provided greater support for the generalizability of our findings. Furthermore, our provisional model should be confirmed with an independent sample and examining should be a focus of future work. Failure to replicate the six-factor solution with parallel ana- lysis indicates the need for further scrutiny into the factor structure of the CABLE derived from EFA and CFA.

Despite our efforts to examine the cultural rele- vance of items in Phase 1, the scale might nonetheless reflect some linguistic nuances that do not translate accurately across cultures – an important consider- ation given the international scope of our study. Finally, although the factor analytic methods used with the present international sample of mourners speak to universal responses to coping with bereave- ment, further investigation is needed to parse out dif- ferences in grief coping across nationalities and racial/ ethnic groups, as well as subsequent modifications of the CABLE to more accurately reflect non-Western coping approaches (e.g., creating a shrine in one’s home for the deceased loved one).

688 A. E. CRUNK ET AL.

Conclusion

We aimed to develop and test a bereavement-specific assessment tool for identifying potentially constructive grief coping strategies, as well as an intervention tool for informing treatment and helping clients to expand their coping repertoire. The CABLE will allow mental health professionals and researchers to (a) assess cop- ing as it relates specifically to bereavement rather than to general life stressors, (b) identify which strategies grievers are currently using to cope with their grief, and (c) better examine associations between coping and grief-related outcomes over time. Furthermore, the CABLE can function as a self-monitoring, self- management tool for grievers. Although the present study provides a beginning, further development of the CABLE will broaden our understanding of how grievers cope following a death (e.g., whether individ- ual strategies and CABLE subscales predict lower grief severity). The CABLE is a metaphor for mourners who feel that the cable of life (literally and figura- tively) has slipped through their hands. The CABLE’s intent is to provide grievers with strategies to help them hang on more securely and move forward to better adaptation to a changed life.

Acknowledgements

The authors gratefully acknowledge the invaluable support of Sandra L. Robinson in this work.

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