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Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 15, 217–226 (2008) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.568

Intrusive Images in Grief: An Exploratory Study

Paul A. Boelen1* and Rafaele J. C. Huntjens2

1 Department of Clinical and Health Psychology, Utrecht University 2 Department of Clinical and Developmental Psychology, University of Groningen

The relevance of intrusive mental imagery to the understanding and treatment of psychological disorders is increasingly acknowledged. Little research has been done on intrusive imagery in grief. Using a sample of 131 mourners, recruited from professional and lay mental health care workers, the current study examined the frequency and correlates of four specifi c intrusive images: (a) positive intrusive memories of the lost person; (b) intrusive images of the death event; (c) re-enactment fantasies; and (d) negative images of the future. Find- ings revealed that these intrusions were common and that the occur- rence of these intrusions hardly varied across subgroups of mourners. All four intrusions were correlated with the severity of complicated grief symptoms, and intrusions (b), (c) and (d) were also correlated with the severity of symptoms of depression and anxiety. Findings have potential theoretical and clinical implications and indicate that a more comprehensive study of intrusions among bereaved people is warranted. Copyright © 2008 John Wiley & Sons, Ltd.

* Correspondence to: Paul A. Boelen, Department of Clinical and Health Psychology, Utrecht University, PO Box 80140, 3508 TC Utrecht, the Netherlands. E-mail: [email protected]

rise to intrusive imagery (Dalgleish & Power, 2004; Reynolds & Brewin, 1999). This study addressed the occurrence and correlates of intrusive images in people confronted with the loss of a loved one.

Although intrusive mental images are also observed in normal grief (Shuchter & Zisook, 1993), they are among the key symptoms of the dis- order complicated grief—a newly defi ned disorder of grief that is not yet included in the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2000) but will likely be established as a formal disor- der in a future edition (Prigerson, Vanderwerker, & Maciejewski, in press). As currently defi ned, complicated grief is a condition that includes symptoms of separation distress (e.g., yearning), disbelief regarding the death, preoccupation with the deceased, and intrusive thoughts and images related to the loss that occur for at least 6 months, to the point of functional impairment (Prigerson et al., in press). Complicated grief has been found to be distinct from depression and PTSD (Bonanno et al., 2007; Prigerson et al., in press). Moreover, complicated grief has been found to be distinct from normal grief, with symptoms of complicated

INTRODUCTION There is growing evidence that intrusive mental images feature prominently in depression, anxiety disorders and other mental disorders (Birrer, Michael, & Munsch, 2007; Hackmann & Holmes, 2004). Intrusive mental images can be defi ned as fragments of specifi c autobiographical events or imaginal extensions of such events that predomi- nantly possess sensory qualities and enter aware- ness suddenly and unintentionally (Hackmann & Holmes, 2004). The experience of a traumatic event is one of the critical events that can give rise to intrusive images. Hence, such images, in the form of reliving scenes of the trauma, are a hallmark of post-traumatic stress-disorder (PTSD; Ehlers, Hackmann, & Michael, 2004). Yet, critical life events other than traumatic events can also give

218 P. A. Boelen and R. J. C. Huntjens

grief being associated with distress and disabil- ity more strongly than symptoms of normal grief (Boelen, van den Bout, de Keijser, & Hoijtink, 2003; Prigerson et al., 1995).

As part of a broader discussion on the differ- ences and similarities between complicated grief and PTSD, several authors have argued that there is overlap in the content of intrusions in both con- ditions, such that both conditions coincide with intrusive imagery of the events that precipitated the condition, viz. the death event and the trau- matic event, respectively (cf. Fox, Reid, Salmon, Mckillop-Duffy, & Doyle, 1999; Shuchter & Zisook, 1993). However, a more dominant view is that intrusive imagery in both conditions has a differ- ent content. For instance, Raphael and Martinek (1997) asserted that in PTSD intrusive images are typically related to scenes of the trauma, whereas grief is more strongly characterized by ‘intense preoccupation with images and memories of the lost person, alive’ (p. 376). Others have also argued that re-experiencing the presence of the lost person is central to grief, emphasizing that this is typically a source of comfort rather than distress (Brewin, Dalgleish, & Joseph, 1996; Ehlers, 2006; Prigerson, Jacobs, Rosenheck, & Maciejewski, 1999).

Although the relevance of intrusive imagery to the understanding of psychological disorders is increasingly acknowledged (Hackmann & Holmes, 2004), there is little research on intrusive images in grief. Studies have shown that intrusions occur after loss. For example, Schut, de Keijser, van den Bout, and Dijkhuis (1991) conducted a 2-year longitudinal study among 128 bereaved spouses. Among other things, they assessed the occurrence of PTSD symptoms—as defi ned in the DSM-III-r (APA, 1987)—with the loss of the spouse being taken as the index event, and found that intrusive symptoms were experienced by approximately 50–80% of the bereaved spouses at different points during this 2-year period. Lehman, Wortman, and Williams (1987) examined the long-term effects of losing a spouse or child in a motor vehicle acci- dent and found that 4–7 years after the loss, 90% of bereaved spouses and 96% of bereaved parents had experienced intrusive memories, thoughts or mental pictures of the deceased during the pre- vious month. Yet, neither one of these studies nor any other study we know of, systematically investigated the content of intrusive images—i.e., whether they represented images of the lost person, the death event and/or other aspects of the loss. Thus, to date, little is known about the specifi c content of intrusions among bereaved individuals

and the relative frequency of intrusions with dif- ferent content. In addition, little is known about differences in the occurrence of intrusions across subgroups of mourners divided by cause of loss and other variables, and the association of intru- sive images with bereavement-related emotional distress.

In this article, a study is described that sought to enhance knowledge about intrusive images in people confronted with loss. Four intrusions were assessed: (a) intrusive memories of nice moments with the lost person; (b) intrusive images of unpleasant moments surrounding the death; (c) re- enactment fantasies; and (d) unpleasant images of the future. The fi rst aim was to examine the fre- quency of these four intrusions. Our main interest was to examine the widespread notion that positive images of the lost person are more common after loss than are intrusions of the scenes of the death—an issue that is relevant to the understanding of the differ- ences versus overlap between grief and PTSD symp- tomatology. Re-enactment fantasies were defi ned as unbidden images of the terminal thoughts and feel- ings the deceased experienced just before he/she died.1 Although, to our knowledge, no studies have systematically examined these phenomena, re- enactment fantasies have been observed in victims of homicidal death (Rynearson, 1996, 2001). Based on clinical observations, it was expected that they are more common among bereaved individuals. For instance, it is conceivable that mourners con- fronted with a loss due to an illness can have fan- tasies of the anguish and loneliness the loved one experienced just before he or she died.

We also assessed negative intrusive images of the future. Although research on intrusive imagery has mostly focused on images of past events, there is evidence that images of negative future events (also called ‘elaborative cognitions’) are involved in depression (Reynolds & Brewin, 1998) and PTSD (Ehlers et al., 2002). Reynolds and Brewin (1998) give the example of a depressed woman who experienced intrusive images of a sick rela- tive dying. Ehlers et al. (2002) describe how, after an accident, a PTSD patient kept having intrusive

1 Although the term ‘re-enactment fantasy’ may seem to imply that this type of intrusion has a higher ‘here and now’ quality than the other types of intrusions assessed in this study, this is not necessarily the case, and there is no evidence that this is so. In spite of its potential misleading connotation, the term ‘re-enactment fantasy’ was retained because it is well known in the bereavement literature.

Intrusive Images in Grief 219

fantasies of himself in a wheelchair. For several reasons, it was conceivable that negative images of the future would also occur among bereaved people. Grief symptoms are associated with PTSD and depression (Prigerson et al., in press), and this likely coincided with shared intrusive imagery. In addition, separation distress—a key symptom of complicated grief—has been known to coincide with the experience of ‘imagined futures without the lost person’ (Raphael & Martinek, 1997, p. 377). Finally, negative appraisals of the future have proven to be critical in complicated grief (Boelen, van den Bout, & van den Hout, 2006) and, as in depression (Reynolds & Brewin, 1998), it was likely that these would not only occur in seman- tic forms but also in the form of intrusive imagery.

A second aim was to study associations of the frequency of the four intrusions with demographic variables (e.g., gender) and loss-related variables (e.g., cause of loss). Generally, knowledge of the correlates of intrusive images and of variation in the occurrence of intrusions across subgroups of mourners could advance our understanding of processes underlying differences in the way subgroups of mourners (e.g., men and women, bereaved partners versus bereaved parents) cope with loss.

Our third aim was to investigate the link between intrusive images and different forms of emotional distress. In dealing with stressful life events, intru- sive images are assumed to refl ect aspects of the event (or extensions thereof) that are most strongly discrepant with pre-existing mental representations of the self and the world, and most particularly in need of fuller emotional processing for recovery to occur (Conway & Pleydell-Pearce, 2000; Dalgleish & Power, 2004). As such, knowledge about the associations of particular intrusions with specifi c forms of bereavement-related emotional problems could inform theorizing about psychological mech- anisms underlying these problems. For instance, the fi nding that intrusive images of the lost person when alive is associated with complicated grief but not depression or anxiety, would make it plausible to suspect that heightened accessibility of memo- ries of the lost person is specifi cally involved in complicated grief (cf. Boelen, van den Hout, & van den Bout, 2006). Similarly, the fi nding that intru- sions of the death event are associated with anxiety but not complicated grief could imply that insuf- fi cient processing of the death event is specifi cally involved in the experience of a continued sense of threat following loss, whereas the absence of such

a specifi c association would suggest that other mechanisms are involved in such anxiety.

In sum, we examined the frequency of four spe- cifi c intrusive images in people confronted with loss, and the associations of these intrusive images with demographic and loss-related variables, and with the severity of symptoms of complicated grief, depression and anxiety.

METHOD Participants

Data were available from 131 bereaved individ- uals who all received some form of psychologi- cal support in the aftermath of their loss. They were recruited via grief counselors, therapists and other caretakers. These caretakers handed out 280 questionnaire packets to mourners at the start of their counseling or therapy process, 136 of which (48.6%) were returned. Data of fi ve persons were removed because of missing values. Because one of our aims was to explore the link of intrusive images with emotional complications following loss, we focused on recruitment of a help-seeking sample rather than a non-clinical sample. Written informed consent was obtained from all par- ticipants. Table 1 shows the characteristics of the sample; most participants were female, most had lost a partner, and losses were mostly due to a non-violent cause (e.g., illness).

Measures

Intrusive Images/Memories To assess intrusive images, four items were con-

structed tapping (a) positive intrusive memories of

Table 1. Background characteristics of the sample (n = 131)

Age (years) (M [SD]) 58.7 (13.7) Sex (n [%]) Women 109 (83.2) Men 22 (16.8) Years of education (M [SD]) 14.5 (3.3) Time from loss in months (M [SD]) 58.4 (75.6) Deceased is (n [%]) Partner 83 (63.8) Child 27 (20.8) Other relative 20 (15.4) Nature of death is (n [%]) Non-violent 83 (63.4) Violent (accident, suicide, homicide) 48 (36.6)

220 P. A. Boelen and R. J. C. Huntjens

the lost person; (b) intrusive images of unpleasant moments surrounding the death; (c) re-enactment fantasies; and (d) unpleasant images of the future. Items were constructed based on clinical observa- tions and literature on grief and are shown in Table 2. Respondents rated how often they usually expe- rienced these intrusions in the preceding month on fi ve-point scales with values 1 (never), 2 (seldom), 3 (sometimes), 4 (frequently) and 5 (all the time).2 The 1-month time frame was chosen because we were interested in the global occurrence of intru- sions over a longer period of time, instead of a brief period.

Complicated Grief Complicated grief was assessed with the Inven-

tory of Complicated Grief-revised (ICG-r), a 30- item questionnaire developed by Prigerson and Jacobs (2001) that taps each of the proposed symptom criteria for complicated grief (Prigerson et al., in press) and other potentially problematic grief responses. Examples of items are ‘Memo- ries of the lost person upset me’, ‘I feel drawn to places and things associated with the lost person’,

and ‘I feel unable to imagine life being fulfi lling without the lost person’. The 29 Dutch ICG-r used in this study has been found to have good psy- chometric properties (Boelen et al., 2003). Among other things, in support of its construct validity, the ICG-r was found to be correlated with concur- rent distress and disability more strongly than the Texas Revised Inventory of Grief (Faschingbauer, Zisook, & DeVaul, 1987), a measure of normal grief. Respondents rate the presence of symptoms in the last month on fi ve-point scales ranging from 1 (never) to 5 (always), resulting in a total score ranging from 29 to 145.

Depression Depression was measured with the Beck Depres-

sion Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Dutch version by Bouman, Luteijn, Albersnagel, & van der Ploeg, 1985). The BDI contains 21 sets of 4 statements representing depressive symptoms, from which the respondent has to choose the most applicable.

State Anxiety The state version of the State-Trait Anxiety Inven-

tory (STAI-S; Spielberger, 1983, Dutch version by Van der Ploeg, 1999) was used to assess state anxiety. Respondents rate the degree to which several (positively and negatively keyed) anxiety symptoms are currently present on four-point scales ranging from 1 (not at all) to 4 (very much). Items are summed to yield a state anxiety score.

Table 2. Endorsement and mean scores of intrusion items

% Endorsement

Never (value 1)

Seldom (value 2)

Sometimes (value 3)

Frequently (value 4)

All the time

(value 5)

M (SD)

I have positive memories of nice moments with [–], that intrude into awareness

1.5 3.8 31.3 47.3 16.0 3.73 (0.83)

I have unpleasant images of moments surrounding the death, that intrude into awareness

26.7 22.9 23.7 20.6 6.1 2.56 (1.25)

Thoughts and fantasies about what [–] possibly experienced right before he/she died, continue to intrude into awareness

19.8 10.7 26.7 26.7 16.0 3.08 (1.35)

I experience unpleasant images/ fantasies about the future, that intrude into awareness

32.8 22.1 22.1 19.8 3.1 2.38 (1.22)

2 Cronbach’s α of the four items was 0.71. Correlations between the intrusion items varied between r = 0.20 (p < 0.05) and r = 0.59 (p < 0.001). The moderate internal consistency and the fact that the shared variance between the intrusion items was maximally 35% indicate that it was acceptable to treat these items as separate variables.

Intrusive Images in Grief 221

RESULTS Descriptive Statistics

Mean scores on the ICG-r, BDI and STAI-S were M = 78.5 (standard deviation [SD] = 24.2), M = 35.97 (SD = 9.8) and M = 44.1 (SD = 12.5), respectively. To examine the level of distress in this sample, the ICG-r score was compared with the ICG-r scores of two samples included in earlier studies. This comparison showed that the current sample had higher complicated grief scores than 30 bereaved university students included in the study of Boelen, Kip, Voorsluijs, and van den Bout (2004; M = 78.5 versus M = 64.8, t(130) = 13.7, p < 0.001) but lower scores than 54 patients who sought psychotherapy for complicated grief from the treatment study of Boelen, de Keijser, van den Hout, and van den Bout (2007; M = 78.5 versus M = 97.3, t(130) = −18.80, p < 0.001).

Frequency of Intrusive Images

Results on the frequency of intrusive images/mem- ories are summarized in Table 2. Positive intrusive memories of the lost person were most prevalent: 63.3% of the participants (n = 83) endorsed that they experienced such memories frequently or all the time; less common were re-enactment fantasies which were experienced frequently/all the time by 42.7% (n = 56); intrusive images of moments sur- rounding the death were experienced frequently/all the time by 26.7% (n = 35); and unpleasant images of the future were experienced frequently/all the time by 22.9% (n = 30).

To further examine the relative frequency of the intrusions, we compared mean scores on the intrusion items (Table 2) using repeated measures analysis of variance (ANOVA). There was a main effect for type of intrusion (F[3, 128] = 47.69, p < 0.001). Post-hoc pairwise comparisons showed that the mean frequency scores differed such that: posi- tive intrusive memories of the lost person (M = 3.72) > re-enactment fantasies (M = 3.08) > intrusive images of moments surrounding the death (M = 2.56) = unpleas- ant images of the future (M = 2.38).

Associations of Demographic and Loss-Related Variables with Intrusive Images

We examined associations of the intrusion items with three demographic variables (i.e. age, gender, number of years of education) and three

loss-related variables (i.e. time since loss, cause of death, kinship to the deceased) using Pearson correlations, t-tests and ANOVAs. The frequency of positive intrusive memories of the lost person was positively correlated with the respondent’s age (r = 0.22, p < 0.05) and was higher in mourners who suf- fered a non-violent loss than in victims of violent losses (t[86.78] = 3.70, p > 0.001). In addition, there was a main effect of kinship (F[2, 129] = 10.21, p < 0.001). Post-hoc pairwise comparisons between the mean scores of those who lost a partner (n = 83), those who lost a child (n = 27) and those who lost ‘another relative’ (n = 20) showed that bereaved partners experienced these intrusions more fre- quently than respondents who lost ‘another relative’ (p < 0.05).

The frequency of intrusive images of moments sur- rounding the death was only associated with time since loss (r = −0.22, p < 0.05). The frequency of re- enactment fantasies was higher in victims of violent loss than in victims of non-violent loss (t[115.94] = 2.16, p < 0.05). Finally, the frequency of unpleasant images of the future was only associated with time since loss (r = −0.24, p < 0.01).

Associations of Intrusive Images with Emotional Distress

First, correlations between the four intrusion items and the ICG-r, BDI and STAI-S were calculated. As shown in Table 3, positive intrusive memories of the lost person were signifi cantly associated with complicated grief, but not with depression and anxiety. The frequency of the other three intrusive images/memories was signifi cantly associated with all three symptom measures.

Next, we consecutively regressed each of the symptom measures on the four intrusion items entered simultaneously, to examine which intru- sive images were most strongly associated with complicated grief, depression and anxiety symptom severity. We felt it was important to control for background variables that infl uenced symptom scores. Therefore, we examined associations of the demographic (e.g., gender) and loss-related (e.g., cause) variables with the symptom measures. There were very few signifi cant associations. Time since loss was the only variable that was associated with both complicated grief (r = −0.25, p < 0.01) and anxiety (r = −0.19, p < 0.05).

Table 4 shows standardized regression coeffi - cients representing the unique associations of the four intrusion items with the symptom measures,

222 P. A. Boelen and R. J. C. Huntjens

when controlling for the shared variance between the intrusions and—in the analyses with compli- cated grief and anxiety—time since loss. Positive intrusive memories of the lost person (β = 0.15, p < 0.05), re-enactment fantasies (β = 0.30, p < 0.001) and unpleasant images of the future (β = 0.43, p < 0.001) had a unique association with complicated grief symptom severity. Re-enactment fantasies (β = 0.27, p < 0.01) and unpleasant images of the future (β = 0.41, p < 0.001) had a unique link with depression symptom severity. Intrusive images of moments sur- rounding the death (β = 0.20, p < 0.05) and unpleas- ant images of the future (β = 0.44, p < 0.001) had a unique association with the severity of anxiety symptoms.

Finally, we examined which intrusive images were specifi cally linked with complicated grief when controlling for depression and anxiety, which were linked with depression when control- ling for complicated grief and anxiety, and which were related with anxiety when controlling for complicated grief and depression. To this end, the

three regressions were rerun, with concomitant symptoms being entered into the equations (e.g., depression and anxiety scores were entered in the regression with complicated grief as dependent variable). Outcomes showed that positive intrusive memories of the lost person (β = 0.15), re-enactment fantasies (β = 0.19) and unpleasant images of the future (β = 0.20, p’s < 0.01) continued to be associated with complicated grief, when controlling for depression and anxiety. None of the intrusions were associ- ated with depression when controlling for compli- cated grief and anxiety. Finally, unpleasant images of the future (β = 0.44, p < 0.001) continued to be associated with anxiety severity, when controlling for complicated grief and depression.

DISCUSSION Using data from mourners recruited via caretak- ers, we examined the occurrence and correlates of four specifi c intrusive images: (a) positive intrusive

Table 3. Correlations of intrusion items with symptom severity

Complicated grief Depression Anxiety

I have positive memories of nice moments with [–], that intrude into awareness

0.36* 0.11 0.17

I have unpleasant images of moments surrounding the death, that intrude into awareness

0.63* 0.47* 0.54*

Thoughts and fantasies about what [–] possibly experienced right before he/she died, continue to intrude into awareness

0.59* 0.44* 0.42*

I experience unpleasant images/fantasies about the future, that intrude into awareness

0.67* 0.54* 0.61*

* p < 0.001.

Table 4. Summary of regression analyses predicting complicated grief, depression and anxiety

Complicated grief Depression Anxiety

First model Relevant demographic/loss variables entered R2 0.06 – 0.03 F 8.67** – 4.43*

Final model Intrusion items added to equation Adjusted R2 0.63 0.35 0.42 F 42.06*** 18.01*** 18.58***

β weights of intrusion items Positive intrusive memories of the lost person 0.15* −0.06 0.02 Intrusive images of unpleasant moments surrounding the death 0.14 0.08 0.20* Re-enactment fantasies 0.30*** 0.27** 0.13 Unpleasant images of the future 0.43*** 0.41*** 0.44***

* p < 0.05. ** p < 0.01. *** p < 0.001.

Intrusive Images in Grief 223

memories of the lost person; (b) intrusive images of moments surrounding the death; (c) re-enactment fan- tasies; and (d) unpleasant images of the future. First, we explored the relative frequency of the four intrusions. Consistent with studies showing that events other than traumas can give rise to intru- sions (Reynolds & Brewin, 1999), we found that intrusive images were common among mourners. Positive memories of the lost person were most frequent, followed by re-enactment fantasies, images of the death event and negative images of the future. These fi ndings confi rm the widely held notion that images of the lost person when alive are more prominent after loss than are images of the death event per se—a feature that distin- guishes grief from PTSD symptomatology (Brewin et al., 1996; Prigerson et al., 1999; Raphael & Martinek, 1997). Unpleasant images of the future were present in two-thirds of all mourners. Thus, as in PTSD (Ehlers et al., 2002) and depression (Reynolds & Brewin, 1998), intrusions in grief are not restricted to images of the past, but can also take the form of images of the future. Re-enact- ment fantasies—unbidden fantasies of what the decedent experienced before dying—occurred in approximately three-quarter of the mourners. Although such images have been observed after homicidal loss (Rynearson, 1996, 2001), they are apparently more common after loss.

In our second round of analyses, we examined associations of demographic and loss-related vari- ables with the frequency of intrusive images. Back- ground variables hardly infl uenced the frequency of intrusions. Age was associated with positive intrusive memories of the lost person and time since death was inversely linked with negative intru- sions of moments surrounding the death and nega- tive images of the future. Yet, correlations were low. Interestingly, positive intrusive memories of the lost person were more frequent in mourners who lost a partner than in those who lost someone other than a partner or child. Thus, it seems that the loss of someone who is strongly involved in one’s past, present and future life coincides with stron- ger accessibility of fond memories than the loss of someone more distant.

It could be expected that negative intrusions of moments surrounding the death would occur more frequently in victims of violent loss than in victims of non-violent loss. Yet, these intrusions did not vary as a function of cause of loss. If future studies replicate this fi nding, that would imply that vari- ables other than the circumstances of the death are responsible for intrusive images of the death

event occurring in its aftermath. In our cognitive– behavioural model of complicated grief (Boelen, van den Hout, et al., 2006), it is postulated that these (and other) intrusions are the result of insuf- fi cient integration of the loss into pre-existing auto- biographical knowledge—a condition that more readily occurs after violent loss, but is supposed to be more strongly linked with other processes such as negative thinking and avoidance. The current fi ndings support this hypothesis.

The third aim of this study was to examine associations of the four intrusive images with bereavement-related emotional distress. Results showed that high levels of intrusive images of moments surrounding the death, re-enactment fantasies and negative images of the future coincided with higher levels of complicated grief, depression and anxiety. This indicates that these particular intrusions are involved in emotional complications following loss. The occurrence of positive intrusive memories of the lost person was positively related with complicated grief, but not depression and anxiety. This fi nding runs counter to the view that, as a healthy mani- festation of continuing ties to the lost person, such positive images are a source of comfort rather than distress (Prigerson et al., 1999).

In a fi nal round of analyses, we regressed each of the symptom measures on the four intrusion items entered simultaneously, to examine which of the intrusions had a unique link with complicated grief, depression and anxiety when controlling for the shared variance between the intrusions. Positive intrusive memories of the lost person, re-enactment fan- tasies and unpleasant images of the future had a unique association with complicated grief. Re-enactment fantasies and unpleasant images of the future had a unique link with depression, and intrusive images of moments surrounding the death and unpleasant images of the future had a unique link with anxiety. These fi ndings gather clues about the relative importance of different intrusions in different emotional prob- lems. That is, positive intrusive memories of the lost person were associated with complicated grief but not depression and anxiety, and intrusive images of moments surrounding the death had a unique link with anxiety but not complicated grief and depres- sion. These fi ndings are consistent with the notion that heightened accessibility of memories of the lost person is specifi cally involved in complicated grief, whereas insuffi cient processing of the death event is specifi cally linked with a continued sense of threat after loss.

The fi ndings also tell us something about the relative importance of the intrusive images that

224 P. A. Boelen and R. J. C. Huntjens

we assessed. That is, positive images of the lost person were the most frequently occurring intrusions, but they seemed least important in predicting emo- tional distress. Conversely, unpleasant images of the future occurred the least frequently but appeared to be most strongly linked with emotional com- plications. The relative importance of images of the future complements results of a prospective study that showed that negative appraisals about the future were critical in maintaining loss-related distress (Boelen, van den Bout, et al., 2006). It thus appears that such appraisals can take the form of verbally accessible cognitions as well as the form of less accessible images—fi ndings that are consistent with our cognitive–behavioural model of complicated grief that proposes that differ- ent representational systems are involved in this condition (Boelen, van den Hout, et al., 2006).

All fi ndings must be treated with caution, given the limitations of this study. A fi rst limitation is that we only assessed a restricted set of intrusions. Hence, this study only allows for an evaluation of the relative frequency (and correlates) of these specifi c intrusions. It is conceivable that, dependent on the circumstances of the loss, some mourners also experience non-assessed intrusions related to, for instance, guilt, embitterment or anger. Future studies using open-ended questions about intru- sions (cf. Michael, Ehlers, Halligan, & Clark, 2005) or dairies completed at the time of their occur- rence (Berntsen, 2001) could be useful for a more comprehensive evaluation of intrusions in grief. A second limitation is that participants were asked to rate the frequency of intrusive images during the preceding month, as a result of which answers may have been affected by mood or memory biases. Another limitation is that we did not assess quali- ties of intrusive images such as sensory modalities (if intrusions were experienced as sounds, words or visual images), vividness and duration. It is pos- sible that these qualities vary across subgroups of mourners (e.g., more vivid images of the loss event after violent losses) and/or relate differently with distress (e.g., visual, but not acoustic intrusions being linked with complicated grief). Future studies are needed to further explore intrusions quality. A fourth limitation is that our cross-sectional design precludes any causal interpretations. A fi fth limi- tation is that—because this study was meant as a fi rst exploration of intrusions in bereaved individu- als—we did not systematically assess who did and did not meet criteria for complicated grief, depres- sion, a specifi c anxiety disorder, or more than one of these conditions. Our fi nal regression analyses

showed that when controlling for the shared vari- ance between symptoms, three of the four intru- sions were associated with complicated grief, none were associated with depression, and one was asso- ciated with anxiety. This suggests that the intru- sions that we tapped are more strongly involved in complicated grief than in bereavement-related depression and anxiety. Nonetheless, the extent to which specifi c, loss-related intrusions are linked with different clinical conditions among bereaved individuals is among the topics that awaits further research. Finally, as it was our intention to explore the link of intrusions with emotional distress, we did not focus on the linkage of intrusive images with normal or uncomplicated grief. Future research is needed to examine whether or not intrusions are differentially related with complicated grief and normal grief.

Notwithstanding these considerations, the current study shows that intrusive images are prominent among bereaved individuals, that the specifi c intrusions we assessed do not vary considerably as a function of demographic and loss-related variables, and that different types of intrusions are involved in complicated grief, depression and anxiety after loss. Generally, our results comple- ment a growing literature showing that intru- sive images are implicated in different forms of psychopathology (Hackmann & Holmes, 2004). Moreover, fi ndings indicate that a more compre- hensive study of intrusions in grief is warranted.

If future studies confi rm that intrusions are important in grief, this could have clinical impli- cations. For instance, exposure to painful intrusive memories in PTSD patients and ‘updating’ these memories with new information has proven to be a powerful intervention in the treatment of PTSD (Ehlers, 2006). Similar interventions could be useful in the treatment of complicated grief. For example, if future research reveals that heightened acces- sibility of memories of the lost person alive main- tains complicated grief, interventions could aim at updating these memories with images of the lost person dead (Ehlers, 2006). If negative imagery of the future will prove important, creating positive images of the future could prove useful. Differ- ent future-oriented interventions (e.g., behavioural activation, goal setting) are already included in our cognitive–behavioural treatment of complicated grief that was recently found to be effective (Boelen et al., 2007). All in all, further research on intrusive images among bereaved individuals may help to elucidate important implicit processes underly- ing recovery from loss and may help to develop

Intrusive Images in Grief 225

interesting new interventions for the treatment of emotional problems in the process of recovery.

ACKNOWLEDGEMENT This research was supported by an Innova- tive Research Incentive Veni Grant (451–06–011) from the Netherlands Organization for Scientifi c Research (NWO) awarded to the fi rst author.

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