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<article xsi:noNamespaceSchemaLocation="http://jats.nlm.nih.gov/publishing/1.1/xsd/JATS-journalpublishing1-mathml3.xsd" dtd-version="1.1" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"><front><journal-meta><journal-id journal-id-type="publisher-id">HPR</journal-id><journal-title-group><journal-title>Health Psychology Research</journal-title></journal-title-group><issn>TBA</issn><eissn>2420-8124</eissn><publisher><publisher-name>Health Psychology Research</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.52965/001c.122543</article-id><article-categories><subj-group subj-group-type="heading"><subject>General</subject></subj-group></article-categories><title>Reflective functioning mediates the relationship between insecure   adult attachment and the severity of prolonged grief symptoms  </title><url>https://healthpr.org/journal/HPR/12/1/10.52965/001c.122543</url><author>GiuntaSerena,ManninoGiuseppe,SideliLucia,C. QuattropaniMaria,LenzoVittorio</author><pub-date pub-type="publication-year"><year>2024</year></pub-date><volume>12</volume><issue>1</issue><history><date date-type="pub"><published-time>2024-08-21</published-time></date></history><abstract>Background
This study aimed to investigate the mediation role of reflective functioning (i.e., certainty and uncertainty about mental states) in the relationship between insecure attachment (i.e., attachment avoidance and attachment anxiety ) and the severity of prolonged grief symptoms.
Methods
A cross-sectional study was conducted with 329 bereaved participants (51.7% females, mean age= 46.94 &amp;plusmn; 14.62 years). Participants completed the Prolonged Grief Scale (PG-13), the Attachment Style Questionnaire (ASQ), and the Reflective Functioning Questionnaire (RFQ). Demographic and bereavement-related information were also collected.
Results
Certainty about mental states fully mediated the relationship between both the attachment avoidance and attachement anxiety and severity of prolonged grief symptoms.
Conclusions
The findings of this study indicate that reflective functioning impairment, specifically certainty about mental states of self and others, mediate the paths from insecure attachment to prolonged grief symptoms. This suggests that improving reflective functioning may contribute to the treatment bereaved individuals at risk of PGD.</abstract><keywords>Clinical psychology, Prolonged grief disorder, Attachment, Reflective functioning, Mentalization</keywords></article-meta></front><body/><back><ref-list><ref id="B1" content-type="article"><label>1</label><element-citation publication-type="journal"><p>1. Freud S. Mourning and melancholia. In: The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol 14. London; 1914&amp;ndash;1916:237-258.2. Johnson JG, First MB, Block S, et al. Stigmatization and receptivity to mental health services among recently bereaved adults. Death Stud. 2009;33(8):691-711. doi:10.1080/074811809030703923. Breen LJ, Penman EL, Prigerson HG, Hewitt LY. Can grief be a mental disorder?: An exploration of public opinion. J Nerv Ment Dis. 2015;203(8):569-573. doi:10.1097/NMD.00000000000003314. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2022. doi:10.1176/appi.books.97808904257875. Mancini AD, Bonanno GA. Resilience in the face of potential trauma: Clinical practices and illustrations. J Clin Psychol. 2006;62(8):971-985. doi:10.1002/jclp.202836. Prigerson HG, Boelen PA, Xu J, Smith KV, Maciejewski PK. Validation of the newly proposed DSM criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry. 2021;20:1-11. doi:10.1002/wps.208237. Bonanno GA, Kaltman S. The varieties of grief experience. Clin Psychol Rev. 2001;21(5):705-734. doi:10.1016/S0272-7358(00)00062-38. Mancini AD, Bonanno GA. Predictors and parameters of resilience to loss: Toward an individual differences model. J Pers. 2009;77(6):1805-1832. doi:10.1111/j.1467-6494.2009.00601.x9. Bowlby J. A Secure Base: Clinical Applications of Attachment Theory. Routledge; 1988.10. Hazan C, Shaver PR. Romantic love conceptualized as an attachment process. J Pers Soc Psychol. 1987;52(3):511-524. doi:10.1037//0022-3514.52.3.51111. Mikulincer M, Shaver PR. An attachment perspective on psychopathology. World Psychiatry. 2012;11(1):11-15. doi:10.1016/j.wpsyc.2012.01.00312. Puig J, Englund MM, Simpson JA, Collins WA. Predicting adult physical illness from infant attachment: A prospective longitudinal study. Health Psychol. 2013;32(4):409-417. doi:10.1037/a002888913. Bartholomew K. Avoidance of intimacy: An attachment perspective. J Soc Pers Relat. 1990;7(2):147-178. doi:10.1177/026540759007200114. Bartholomew K, Horowitz L. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol. 1991;61(2):226-244. doi:10.1037/0022-3514.61.2.22615. Jinyao Y, Xiongzhao Z, Auerbach RP, et al. Insecure attachment as a predictor of depressive and anxious symptomology. Depress Anxiety. 2012;29(9):789-796. doi:10.1002/da.2195316. Musetti A, Pingani L, Zagaria A, et al. Insecure adult attachment and reflective functioning as mechanisms of the relationship between traumatic life events and suicidal ideation: A path analysis. Front Psychol. 2022;13(16):985148. doi:10.3389/fpsyg.2022.98514817. Cortes-Garcia L, Takkouche B, Seoane G, Senra C. Mediators linking insecure attachment to eating symptoms: A systematic review and meta-analysis. PloS one. 2019;14(3):e0213099. doi:10.1371/journal.pone.021309918. Lenzo L, Sardella A, Maisano Branca G, et al. The interplay between burnout risk and attachment styles among palliative care practitioners. Psychodyn Pract. Published online 2021:18. doi:10.1080/14753634.2021.192230519. Bowlby J. Attachment and Loss: Vol. 3. Sadness and Depression. Basic Books; 1980.20. Sekowski M, Prigerson HG. Disorganized attachment and prolonged grief. J Clin Psychol. 2022;78(9):1806-1823. doi:10.1002/jclp.2332521. Fraley RC, Bonanno GA. Attachment and loss: A test of three competing models on the association between attachment-related avoidance and adaptation to bereavement. Pers Soc Psychol Bull. 2004;30:878-890. doi:10.1177/014616720426428922. Boelen PA, Klugkist I. Cognitive behavioral variables mediate the associations of neuroticism and attachment insecurity with prolonged grief disorder severity. Anxiety Stress Coping. 2011;24:291-307. doi:10.1080/10615806.2010.52733523. Huh HJ, Kim KH, Lee HK, Chae JH. Attachment styles, grief responses, and the moderating role of coping strategies in parents bereaved by the Sewol ferry accident. Eur J Psychotraumatol. 2017;8:1424446. doi:10.1080/20008198.2018.142444624. Lai C, Luciani M, Galli F, et al. Attachment Style Dimensions Can Affect Prolonged Grief Risk in Caregivers of Terminally Ill Patients With Cancer. Am J Hosp Pall Medicine. 2014;32(8):855-860. doi:10.1177/104990911454794525. Maccallum M, Bryant RA. A cognitive attachment model of prolonged grief: Integrating attachments, memory, and identity. Clin Psychol Rev. 2013;33(6):713-727. doi:10.1016/j.cpr.2013.05.00126. Maccallum F, Bryant RA. Prolonged grief and attachment security: A latent class analysis. Psychiatry Res. 2018;268:297-302. doi:10.1016/j.psychres.2018.07.03827. Lenzo V, Quattropani MC. Psychological factors and prosociality as determinants in grief reactions: Proposals for an integrative perspective in palliative care. Front Psychol. 2023;14:1136301. doi:10.3389/fpsyg.2023.113630128. Lenzo V, Sardella A, Musetti A, Faraone C, Quattropani MC. Toward a preventive approach to prolonged grief disorder in palliative care: Insecure attachment moderates the impact of perceived support on the severity of symptoms. Plos One. 2022. doi:10.1371/journal.pone.026628929. Katznelson H. Reflective functioning: A review. Clin Psychol Rev. 2014;34(2):107-117. doi:10.1016/j.cpr.2013.12.00330. Fonagy P, Gergely G, Jurist E, Target M. Affect. Regulation, Mentalization, and the Development of the Self. Other Press; 2002.31. Jewell T, Collyer H, Gardner T, et al. Attachment and mentalization and their association with child and adolescent eating pathology: A systematic review. Int J Eat Disord. 2016;49:354-373.32. Fonagy P, Luyten P, Moulton-Perkins A, et al. Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire. PLoS ONE. 2016;11:e0158678. doi:10.1371/journal.pone.015867833. Morandotti N, Brondino N, Merelli A, et al. The Italian version of the Reflective Functioning Questionnaire: Validity data for adults and its association with severity of borderline personality disorder. PLoS ONE. 2018;13:e0206433. doi:10.1371/journal.pone.020643334. Rudden M, Milrod B, Target M, Ackerman S, Graf E. Reflective functioning in panic disorder patients: A pilot study. J Am Psychoanal Assoc. 2006;54(34):1339-1343. doi:10.1177/0003065106054004010935. MacBeth A, Gumley A, Schwannauer M, Fisher R. Attachment states of mind, mentalization, and their correlates in a first-episode psychosis sample. Psychol Psychother. 2011;84:42-57.36. Luyten P, Lemma A, Target M. Mentalizing and depression. In: Bateman A, Fonagy P, eds. Mentalizing in Mental Health Practice. American Psychiatric Publishing Inc.; 2012:385-418.37. Quattropani MC, Geraci A, Lenzo V, Sardella A, Schimmenti A. Failures in Reflective Functioning, Dissociative Experiences, and Eating Disorder: A Study on a Sample of Italian Adolescents. J Child Adolesc Trauma. 2022;15:365-374. doi:10.1007/s40653-022-00450-938. Luyten P, Campbell C, Allison E, Fonagy P. The mentalizing approach to psychopathology: State of the art and future directions. Annu Rev Clin Psychol. 2020;16:297-325.39. Levi-Belz Y, Lev-Ari L. Thinking for healing: The role of mentalization deficits as moderator in the link between complicated grief and suicide ideation among suicide-loss survivors. Death Stud. Published online 2022:1-10. doi:10.1080/07481187.2022.206570740. Lenzo V, Sardella A, Musetti A, Petralia MC, Grado I, Quattropani MC. Failures in Reflective Functioning and Reported Symptoms of Anxiety and Depression in Bereaved Individuals: A Study on a Sample of Family Caregivers of Palliative Care Patients. Int J Environ Res Public Health. 2022;19(19):11930. doi:10.3390/ijerph19191193041. Nazzaro MP, Boldrini T, Tanzilli A, Muzi L, Giovanardi G, Lingiardi V. Does reflective functioning mediate the relationship between attachment and personality? Psychiatry Res. 2017;256:169-175. doi:10.1016/j.psychres.2017.06.04542. Badoud D, Prada P, Nicastro R, et al. Attachment and reflective functioning in women with borderline personality disorder. J Pers Disord. 2018;32(1):17-30. doi:10.1521/pedi_2017_31_28343. Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121. doi:10.1371/journal.pmed.100012144. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.45. World Health Organization. ICD-11.6B42 Prolonged grief disorder. http://id.who.int/icd/entity/118383231446. De Luca ML, Tineri M, Zaccarello G, Grossi G, Altomonte A, Slavic E, et al. Adattamento e validazione del questionario &amp;ldquo;PG-13&amp;rdquo; Prolonged Grief nel contesto italiano. Riv It Cur Pall. 2015;17(2):84-92. doi:10.1726/3052.3046647. Feeney JA, Noller P, Hanrahan M. Assessing adult attachment in adults. In: Sperling MB, Berman WH, eds. Attachment in Adults: Clinical and Developmental Perspectives. Guilford Press; 1994:128-152.48. Fossati A, Feeney JA, Donati D, et al. On the dimensionality of the attachment style questionnaire in Italian clinical and nonclinical participants. J Soc Pers Relat. 2003;20(1):55-79. doi:10.1177/0265407503020100349. Hayes AF. An Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. Guilford Press; 2013.50. Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods. 2004;36(4):717-731.51. Mikulincer M. An attachment perspective on disordered grief reactions and the process of grief resolution. Grief Matters. 2008;11(1):34-37.52. Wijngaards-de Meij L, Stroebe M, Schut H, et al. Patterns of attachment and parents&amp;rsquo; adjustment to the death of their child. Pers Soc Psychol Bull. 2007;33(4):537-548.53. Fonagy P, Target M. Attachment and reflective function: Their role in self-organization. Dev Psychopathol. 1997;9(4):679-700. doi:10.1017/S095457949700139954. Cologon J, Schweitzer RD, King R, Nolte T. Therapist reflective functioning, therapist attachment style and therapist effectiveness. Adm Policy Ment Health. 2017;44:614-625. doi:10.1007/s10488-017-0790-555. Cucchi A, Hampton JA, Moulton-Perkins A. Using the validated Reflective Functioning Questionnaire to investigate mentalizing in individuals presenting with eating disorders with and without self-harm. PeerJ. 29(2018):e5756. doi:10.7717/peerj.575656. Brugnera A, Zarbo C, Compare A, et al. Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists. Psychother Res. 2021;31(2):247-257.57. M&amp;uuml;ller S, Wendt LP, Spitzer C, Masuhr O, Back SN, Zimmermann J. A critical evaluation of the Reflective Functioning Questionnaire (RFQ). J Pers Assess. 2022;104(5):613-627. doi:10.1080/00223891.2021.198134658. Woźniak-Prus M, Gambin M, Cudo A, Sharp C. Investigation of the Factor Structure of the Reflective Functioning Questionnaire (RFQ-8): One or Two Dimensions? J Pers Assess. 2022;104(6):736-746. doi:10.1080/00223891.2021.201450559. Bizzi F, Riva A, Borelli JL, et al. The Italian version of the Reflective Functioning Questionnaire: Validity within a sample of adolescents and associations with psychological problems and alexithymia. J Clin Psychol. 2022;78:503-516. doi:10.1002/jclp.23218</p><pub-id pub-id-type="doi"/></element-citation></ref></ref-list></back></article>
