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OMEGA—Journal of Death and Dying

0(0) 1–45
A Systematic Review ! The Author(s) 2019
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DOI: 10.1177/0030222819893139
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With Bereavement
(1999–2016)
Jennifer Fiore1
Abstract
This systematic review addressed the question whether the Dual Process Model of
Coping with Bereavement (DPM) accurately represents the bereavement experi-
ence, and whether DPM-based interventions are more effective than traditional
grief therapy. Twenty databases were searched to identify publications related to
the DPM between 1999 and June 30, 2016. Coded material included source, title,
research design, research question(s), data source, measures, method, and out-
comes. Of the 474 articles initially identified, 86 underwent full-text review, with
22 quantitative or mixed-methods studies included. The DPM accurately represents
the bereavement experience and can be used to understand how bereaved individ-
uals cope. Interventions based upon the DPM may be more effective than traditional
grief therapy. Further research is needed to test both the model and intervention
design, especially in regard to oscillation, with use of consistent measures
between studies.
Keywords
bereavement, Dual Process Model of Coping with Bereavement, Stroebe, Schut,
systematic review
1
Western Michigan University, Kalamazoo, MI, USA
Corresponding Author:
Jennifer Fiore, Western Michigan University, 1903 W. Michigan Ave., Kalamazoo, MI 49009, USA.
Email: jennifer.fiore@wmich.edu
2 OMEGA—Journal of Death and Dying 0(0)
A Systematic Review of the Dual Process Model of Coping

Grief is a natural part of life as people lose jobs, relationships, or significant
people in their lives due to death. Historically, researchers have viewed grief in
stage or phase models (Kübler-Ross, 1969; Rando, 1983; Wolfelt, 1996) or have
included tasks of mourning to signify how the bereaved copes in response to the
death of a loved one (Worden, 1991, 1996). The Dual Process Model of Coping
with Bereavement (DPM), developed by Margaret Stroebe and Henk Schut
(1999), distinguished rumination from Freud’s theory of grief work and inte-
grated existing theories from both stress and coping and bereavement to create a
new model of coping which to more accurately define the stressors related to the
bereavement experience. M. Stroebe and Schut (1999) identified limitations of
the existing grief work models to include (a) the concept that bereaved people
only deal with one stressor at a time rather than multiple stressors, (b) the view
that bereavement is only an intrapersonal process that does not account for
interaction with others or the ways bereaved can grow after the spouse’s
death, (c) the lack of supportive evidence that the grief work hypothesis is
accurate for the bereavement experience, and (d) the limited ability of the
grief work hypothesis to function across cultures and between genders. These
limitations led to formation of the DPM.
The conceptual framework for the DPM incorporated Cognitive Stress
Theory (CST; Lazarus & Folkman, 1984), the Stress Response Syndrome
(SRS; Horowitz, 1986), Two-Track Model of Bereavement (Rubin, 1981), and
the Model of Incremental Grief (Cook & Oltjenbrun, 1998), to account for the
complex nature of bereavement. A synopsis of the theories provided below is
offered to give context to understand the DPM framework.
CST (Lazarus & Folkman, 1984) postulates that negative health outcomes
result when a person assesses a situation as challenging or stressing and becomes
stressed when the perceived demands are greater than his or her personal resour-
ces. CST uses both problem-focused coping (the ability to manage and change
the problem) for challenges/stressors that can be altered and emotion-focused
coping (the ability to manage the emotions related to the problem) for
unchangeable challenges/stressors. Within the CST framework, bereavement
would be the overall stressor, with ongoing stressors being a loss of the skills/
tasks the deceased contributed to the relationship. M. Stroebe and Schut (1999)
identified a limitation of CST related to bereavement in that it uses
confrontation-avoidance which does not account for bereaved individuals
having multiple stressors to manage at any given time or needing to take on
additional tasks previously completed by the deceased. M. Stroebe and Schut
then looked toward the SRS theory to further build the conceptual framework
of the DPM to account for addressing multiple stressors simultaneously.
SRS defines a normal response to a traumatic event when an individual is
able to maintain function even after a traumatic event (Horowitz, 1986).
Fiore 3
Responses that differ from the population norm become chaotic and involve
phases of intrusion and avoidance. Intrusion is the involuntary reexperiencing of
feelings or ideas related to the traumatic event (i.e., disruptions in sleep, dream-
ing, and hypervigilance), while avoidance happens when an individual is in
denial, and can include amnesia, loss of ability to visually recall memories, or
disassociation to the person or event (Horowitz, 1986). M. Stroebe and Schut
(1999) concluded that the SRS model did not completely define the grief
response since it worked to understand the source of the intrusion-avoidance
behavior instead of how confrontation and avoidance are used during bereave-
ment as a coping mechanism.
Rubin’s (1981) Two-Track Model of Bereavement is based on one track set-
ting the other track in motion as an individual works through three stages in
response to a loss. Track one is outcome based, focusing on the psychological
and social reaction to bereavement, and track two relates to how attachment to
the deceased changes into a new, ongoing relationship (Rubin, 1981). The lim-
itation of the Two-Track Model of Bereavement is that it lacks an explanation
of the cognitive processes bereaved go through between the stressor and the
outcome occur (M. Stroebe & Schut, 1999).
The Model of Incremental Grief developed by Cook and Oltjenbruns (1998)
describes how one loss triggers another, with grief intensifying with each addi-
tional loss. Bereaved individuals who experience a change in his or her relation-
ship with the deceased prior to the time of death are considered to suffer from a
secondary loss which can be assessed as stressful and lead to secondary grief.
The primary loss due to death and the secondary loss related to a changed
relationship prior to death can result in intensified grief due to multiple losses
(Cook & Oltjenbruns, 1998). The inclusion of this model in the DPM framework
is important, as it includes the family perspective instead of only an intraper-
sonal perspective.
The DPM of Coping With Bereavement

The DPM incorporates both loss-oriented (LO) and restoration-oriented (RO)
coping to address the different types of stressors bereaved face on a daily basis,
with the concept of oscillation guiding the process between the two coping
strategies. LO coping includes traditional grief work and ruminating about
the deceased, life together before the death, and events related to the death.
LO coping is flexible and accounts for the expected or unexpected emotions
related to bereavement. Early bereavement uses more LO coping, when
bereaved initially experience more negative affect. Over time, affect becomes
more positive, and the bereaved use fewer LO coping strategies. LO coping is
similar to the interpretations of Cook and Oltjenbruns (1998) and Rubin (1981)
which focus on the bond and attachment with the deceased and the importance
of a continued relationship with the deceased moving forward (M. Stroebe &
Schut, 1999).
RO coping refers to secondary sources of stress related to bereavement that
increase the sense of loss and can cause additional stress while the bereaved learn
to manage new tasks previously managed by the deceased. RO coping also
addresses role change, the new identity assumed by the bereaved, and the emo-
tions related to role and identity change. RO coping is comparable to Cook and
Oltjenbruns’ (1998) Model of Incremental Grief in regard to secondary loss, but
goes beyond adjusting to a changed relationship with the deceased (M. Stroebe
& Schut, 1999).
Oscillation is the essential element of the DPM process that moves
the bereaved between LO and RO coping strategies. Oscillation allows the
bereaved to alternate between confronting (i.e., actively grieving) and
avoiding grief (i.e., avoid memories, distraction), allowing for adjustment over
time. Based on Parkes’ Psychosocial Transitions Model, oscillation describes
the balance between loss due to death and gains due to positive changes
(Parkes, 1993). Oscillation between LO and RO is theoretically necessary for
adaptive coping and adjustment to life without the deceased (M. Stroebe &
Schut, 1999).
In forming the DPM, Stroebe and Schut expanded on Worden’s four tasks of
grieving. Worden’s first task “to accept the reality of the loss” is addressed in
Stroebe and Schut’s addition of the “reality of the changed world.” Worden’s
next task “to experience the pain of grief” was altered by Stroebe and Schut “to
take time off from grieving.” The third task of “adjusting to the bereaved not
being in the physical environment” was expanded by Stroebe and Schut to also
include the subjective environment. The fourth task of “relocating the deceased
emotionally” in order to move on was altered to include the “need to develop
new roles, identities and relationships” (M. Stroebe & Schut, 1999, p. 215). See
Figure 1 for graphic representation of DPM.
Further developments in CST after the development of the DPM in 1999
resulted in an update to the DPM in 2001, adding the reappraisal of positive
and negative affect (M. Stroebe & Schut, 2010) and the extension to the family
level of the model that included an interpersonal perspective. The relationship
between coping and affect for caregivers depends on problem-focused coping
and positive reappraisal. Problem-focused coping identifies behaviors or
thoughts necessary for change, which gives caregivers a sense of control and
mastery during the caregiving phase, and results in more positive affect after
the death. Positive reappraisal occurs when people focus on the positive of
what is happening or has happened relative to personal growth (Folkman &
Moskowitz, 2000). Positive affect can also maintain improved problem- and
emotion-focused coping during chronic stressful events. From these outcomes,
the revised DPM includes confrontation-avoidance as part of the oscillation
process between positive and negative affect reappraisal (M. Stroebe & Schut,
Fiore 5
Figure 1. Dual Process Model of Coping with Bereavement (1999).

Source: Figure 1 of M. S. Stroebe and Schut (1999). Copyright 1999 by M. S. Stroebe and
H. A. W. Schut. Reprinted with permission.
Figure 2. Appraisal processes in the Dual Process Model of Coping with Bereavement (2010).
Source: Figure 2 of M. S. Stroebe and Schut (2010). Copyright 2010 by M. S. Stroebe. Reprinted
with permission.
2010). The end result indicates bereaved oscillate between positive and nega-
tive reappraisal in regard to both LO and RO coping (see Figure 2). An
additional update to the DPM occurred in 2015 (DPM-R), elaborating and
specifying the model from the individual to the family level due to recognition
Figure 3. Dual Process Model of Coping with Bereavement-Revised (2015).

Source: Figure 1 of M. S. Stroebe and H. Schut (2015). Copyright 2015 by SAGE Publishing.
Reprinted with permission.
that people do not grieve alone, and that family dynamics can impact indi-
vidual adjustment in either positive or negative ways. The DPM-R includes
family-level stressors (i.e., stressors that family members alone or together
experience during adjustment), and family-level coping (i.e., grief work indi-
viduals and family members work through together; M. Stroebe & Schut,
2016). For both the individual and family level, the extension/adaptation
of Worden’s tasks are presented relative to both LO and RO coping (see
Figure 3).
With multiple theories, stage or phase models of grief, it is necessary to
understand which of the models most accurately fits the bereavement experi-
ence. The DPM has been an established model since 1999 with extensive
referencing of the model in research, but a limited research base testing the
model. This study is the first systematic review related to the DPM in order
to answer the following questions:
1. Does the DPM accurately represent the bereavement experience for a

bereaved adult to achieve adaptive coping?
2. Are interventions based on the DPM more effective for bereaved adults to
achieve adaptive coping compared to traditional grief therapy for grief, stress,
and coping?
Fiore 7
Method
Identification of Relevant Studies
This systematic review examined whether the DPM accurately represents the
bereavement experience, and if interventions based on the DPM were more
effective than traditional grief therapy for addressing grief, stress, and coping.
The following inclusion and exclusion criteria were used to determine appropri-
ateness of inclusion for each study, with the inclusion criteria being established
with guidance outlined in M. Stroebe and Schut’s (2010) update on the DPM.
Inclusion Criteria
• Research was conducted/published after 1999 when the DPM was intro-
duced/published by Stroebe and Schut.
• Quantitative, longitudinal, and mixed-methods studies.
• Research design addressed three components of the DPM (LO coping,
RO coping, and oscillation).
• Study examined the model or used the model as a framework for intervention
design.
• Participants were bereaved family members or significant others.
• Studies in English to limit the possibility of translation errors.
Exclusion Criteria
• Review articles and book chapters as a study was not conducted.
• Qualitative studies were excluded to limit the scope of the review.
• Articles that applied components of DPM to results or within discussion
section, with no inclusion of DPM in the methodology of the study.
• Dual-process model not developed by Stroebe and Schut.
• Bereaved were professional caregivers (e.g., registered nurse [RN], social
work) or colleagues/classmates to the deceased.
• Studies not in English.
Search Strategies
Databases searched included PsycINFO, EBSCO, Google Scholar, JSTOR,
Pubmed, MEDLINE, SAGE, Nursing & Allied Science, Lippincott Williams
Wilken, Springer, Expanded Academic ASAP, Science Direct, Academic One
File, PsychInfo, Psychiatry Online, Omni File, Taylor & Francis, Web of
Science, CINAHL, and HealthSTAR databases. Search terms included Dual
Process Model of Coping with Bereavement, Dual Process Model of Coping inter-
ventions, Margaret Stroebe, Henk Schut, bereavement, grief, coping, and coping
behavior. For example, a search on the CINAHL database searched for “dual
process model of coping with bereavement” with limits set for full text and
published beginning in 1999. The initial search yielded 474 entries published
between 1999 and June 30, 2016.
Data Extraction
An initial table was created to track all entries related to the DPM. The table
included (a) author(s), (b) article title, (c) year published, (d) type of research, (e)
included/excluded, (f) reason for exclusion, (g) search engine, (h) search term,
and (i) if pdf of article was obtained. The researcher created an article review
process (see Online Appendix A) and then conducted the first level of review
assessing eligibility through reference citation review. Duplicate entries, book
chapters, qualitative studies, publications where the population studied was not
family/significant other as indicated in the title, and publication dates before
1999 were excluded. The second level of review completed by the researcher
included screening abstracts to exclude publications that did not meet inclusion
criteria. Publications were excluded after review of the abstract due to qualita-
tive study design, the population not being bereaved family/significant other,
publication was a review article, related to a conference proceeding, and pub-
lications not written in English.
In preparation for the third level of review, the researcher created an eligi-
bility review checklist (see Online Appendix B) to guide the third-level review
process, with the final decision for inclusion/exclusion indicated on the Excel
spreadsheet. The researcher then independently read all 86 articles and placed
the information for the review into a new table summarizing seven categorical
features of each study: (a) source, (b) title, (c) research design, (d) research
question(s), (e) data source, (f) measures, (g) method, and (h) outcomes. The
studies that underwent full review for consideration in this systematic review are
listed in Online Appendix C. After coding each article, the researcher randomly
split the 86 sources into two separate groups for a reliability check of the
researcher’s independent third level of review. The third level of review reliabil-
ity check was completed by two groups, each consisting of three music therapy
students (one graduate and two undergraduate in each group) who worked
together to review articles and extract data. Prior to beginning, the researcher
held a 90-minute training session for the students to explain the protocol, dem-
onstrate the article review process with use of the eligibility review checklist, and
indicate the final decision for inclusion/exclusion on the Excel spreadsheet. The
group then reviewed and coded an article together to practice the established
protocol and achieved consensus regarding how to the code the article. After
training was complete, each group reviewed 43 articles independently. Data
extraction included (a) author(s), (b) title, (c) year, (d) type of study, (e)
include/exclude, and (f) reason for exclusion. A spreadsheet for each traid’s
43 articles contained the same content areas for review as the primary
Fiore 9
researcher’s. The primary researcher met with each group after data extraction
was completed to compare and discuss any discrepancies in order to reach group
consensus.
Bias for data extraction was minimized with three strategies: (a) the use of
groups consisting of three students each, (b) an independent review and data
extraction by each student in the group of three as well as by the researcher, and
(c) a discussion between the researcher and the three group members in order to
reach a consensus when discrepancies arose.
Results
The search for relevant articles published between 1999 and June 30, 2016
yielded 474 entries. After initial review of the reference citation, 214 articles
were excluded, leaving 260 articles. Next, abstracts were screened based on
inclusion/exclusion criteria, excluding 174 articles. The remaining 86 articles
for full-text review were split among two groups (43 articles for each group)
and independently reviewed by both the primary researcher and three additional
reviewers, with discrepancies being determined through discussion in order to
reach group consensus. Based on the full-text reviews, an additional 64 articles
were excluded (see Online Appendix C for full-text reference list), resulting in a
final data set of 22 articles. Excluded articles (n ¼ 64) included studies that
referenced the DPM but did not test the model (n ¼ 33); studies that related
study outcomes to the DPM but did not test the model (n ¼ 8); studied demo-
graphics, not the DPM (n ¼ 1); qualitative study (n ¼ 6); the population were not
bereaved family/significant other (n ¼ 2); a literature review article (n ¼ 1); study
did not reference M. Stroebe and Schut (1999) or Stroebe and Schut (2010) in
study design (n ¼ 2); intervention did not include LO, RO, and oscillation
(n ¼ 2); study did not relate to the DPM established by Stroebe and Schut
(n ¼ 6); the DPM-based intervention was discussed with the study being on-
going and no results included (n ¼ 1); or data analysis for treatment and control
groups were combined resulting in inability to interpret findings (n ¼ 2). The
PRISMA Flow Diagram (see Figure 4) illustrates the process and reasons for
exclusion.
Two data sets, “Changing Lives of Older Couples” (CLOC) and “Living
After Loss” (LAL) comprise almost a quarter of the DPM research reported
in this systematic review. The CLOC data set was funded by the National
Institutes of Health (NIH) and granted to the University of Michigan. CLOC
was a “multi-wave prospective study of spousal bereavement” (Neese,
Wortman, & House, n.d.) including 1,532 older married men and women
from the Detroit metro area. Data collection included initial interviews and
follow-up interviews with bereaved spouses and control participants at 6, 12,
and 48 months post loss, with the study running from 1987 to 1993. The data set
includes over 3,000 variables related to older adults social, psychological, and
Assessed for Excluded (n=214)

eligibility through ♦ Duplicate records removed (n=44)
reference citation ♦ Title indicated population was not bereaved
(n=474) family or significant other (n=90)
♦ Title indicated study was qualitative (n=23)
♦ Book chapter (n=52)
♦ Published before 1999 (n=2)
♦ Unable to locate full article (n=3)
Abstracts screened Excluded (n=174)

(n=260) ♦ Qualitative Indicated in Abstract (n=43)
♦ Population not bereaved family or significant other (n=28)
♦ Literature Review article (n=72)
♦ Conference Proceeding (n=2)
♦ Not in English (n=5)
♦ Not an intervention study (n=10)
♦ Does not relate to DPM (n=14)
Excluded (n=64)
Reliability Review ♦ Referenced, did not test model (n=33)
of articles (n=86) ♦ Related findings to DPM, but did not test model (n=8)
♦ Studied demographics, not DPM (n=1)
♦ Qualitative (n=6)
♦ Population not bereaved family/significant other (n=2)
♦ Literature review article (n=1)
♦ Stroebe & Schut 1999 or 2010 not referenced (n=2)
♦ Intervention did not include LO, RO and oscillation (n=2)
♦ Did not relate to DPM (n=6)
♦ Outcomes not reported, study is ongoing (n=1)
♦ Unable to interpret findings as treatment and control groups
were combined together in data analysis (n=2)
Studies Included in
analysis (n=22)
Figure 4. PRISMA flow diagram. LO ¼ loss-oriented; RO ¼ restoration-oriented;

DPM ¼ dual process model.
physical functioning. CLOC data sets, codebook, and questionnaire are avail-
able online at http://cloc.isr.umich.edu/. Studies based on the CLOC data set
include Pai and Carr (2010) and Richardson (2006). The LAL project was funded
by the National Institutes on Aging and was conducted in a partnership
Fiore 11
between the University of Utah and San Francisco State University. LAL includ-
ed 298 bereaved men and women, comparing traditional grief therapy to 14-week
sessions based upon the DPM incorporating LO and RO session components
(Lund, Caserta, Utz, & de Vries, 2010). Participants completed a questionnaire
preintervention, and then three additional questionnaires after sessions ended,
with the study running from 2005 to 2009. Three studies included in this system-
atic review are based upon the LAL data set including Caserta, Utz, Lund,
Swenson, and de Vries (2014); Caserta, Lund, Utz, and de Vries (2009); and
Lund et al. (2010).
Does the DPM Accurately Represent the Bereavement Experience for

a Bereaved Adult to Achieve Adaptive Coping?
Ten studies examined the ability of the DPM to accurately reflect the bereave-
ment experience (Caserta & Lund, 2007; Caserta et al., 2009; Delespaux,
Ryckebosch-Dayez, Heeren, & Zech, 2013; Dunn, 2015; Gerrish, Neimeyer, &
Bailey, 2014; Knowles & O’Connor, 2015; Pai & Carr, 2010; Richardson, 2006;
Richardson & Balaswamy, 2001; Meij et al., 2008) and are summarized in
Table 1. Study types included five quantitative, one cross-sectional quantitative,
two mixed methods, one prospective two-stage probability study, and one lon-
gitudinal study.
Systematic evaluation of the quality of the included studies was difficult to
assess across studies. The 10 included studies used 29 different measures, with 6
measures being used 2 or 3 times, and rest being used only once. The Inventory
of Daily Widowed Life (IDWL) was used in three studies, while the Texas
Revised Inventory of Grief (TRIG), UCLA Loneliness Scale, Stress-Related
Growth Scale (SRGS), Symptom Checklist 90, and Bradburn’s Affect Balance
Scale (ABS) were used in two studies. The indication of sufficient power was
another challenge in evaluating study quality, with only one study indicating a
power analysis was run (Dunn, 2015). Finally, only 4 of the 10 studies had a
comparison group (Caserta & Lund, 2007; Pai & Carr, 2010; Richardson, 2006;
Richardson & Balaswamy, 2001), with only Pai and Carr (2010) having a true
control group, though the groups were unbalanced. The other comparison
groups were based on length of bereavement (e.g., less than/greater than
500 days bereaved; 2–5 months vs. 12–15 months bereaved; or men vs. women).
The DPM accurately represents the bereavement experience and can be used
to understand how bereaved individuals cope as well as how coping flexibility in
the use of both LO and RO activities supports adaptive coping. In an attempt to
further illustrate the connection between study outcomes and the DPM, the
author generated Figure 5. During this process, it became evident that most
results were easily categorized as LO or RO coping, and that no specific study
results could be related to oscillation. The study outcomes that did not specif-
ically relate to either LO or RO coping related to variables that mediate the
Table 1. Included Studies Investigating the Ability of the DPM to Accurately Represent the Bereavement Process.
Source Title Design/Framework Research question(s) Data source Measures Method Outcomes
Caserta and Toward the develop- Quantitative based on Does the IDWL mea- 79 widows and wid- Demographic and Measures listed were No correlation
Lund (2007) ment of an the dual process sure the degree in owers, aged 45 background infor- analyzed through between LO and
Inventory of Daily model (DPM) which widows and years and older, mation descriptive statis- RO subscales as
Widowed Life widowers engage in who are bereaved IDWL tics, one-way they are indepen-
(IDWL): Guided by coping processes 12 to 15 months Texas Revised ANOVA, explana- dent dimensions,
the dual process associated with LO, Inventory of Grief tory power tests, and seen as
model of coping RO, and oscillation (TRIG) two-way ANOVAs, “independent, nor-
with bereavement between the two? Geriatric Depression and Scheffe post mally distributed
Scale—Short-Form hoc pairwise and internally con-
UCLA Loneliness analysis. sistent” (p. 523).
Scale—Short Form LO and RO subscales
Coping Self-Efficacy were “substantially
Scale correlated with
23-item scale to rate oscillation bal-
perceived skills of ance.”
self-care and daily Analysis indicated
living tasks or recently bereaved
activities had better oscilla-
Stress-Related tion balance,
Growth Scale- though those
Short Form (SRGS- bereaved longer
SF) had more emphasis
on RO than
recently bereaved
(continued)
Table 1. Continued.
High LO levels and

low restoration-
focused coping
were linked with
higher levels of
grief, depression,
and loneliness,
while less LO and
more RO coping
were linked with
greater coping effi-
cacy based on
analyses.
RO directly related to
level of self-care,
daily living skills,
and personal
growth.
Six dimensions of
oscillation identi-
fied for further
investigation.
Caserta et al. Stress-related growth Quantitative based on Is there a relationship 292 recently bereaved SRGS-SF Measures listed were Religion a protective
(2009) (SRG) among the the DPM between Stress (2–6 mo) Self-esteem scale analyzed through factor.
recently bereaved Related Growth Part of “Living After TRIG descriptive statis- Bivariate correlation
(SRG) and resour- Loss” data set IDWL tics, open-ended showed strongest
ces, sociodemo- (baseline only) questions regarding associations with
graphic character- growth, and multi- SRG was with RO
istics, situational variate regression. coping.
(continued)
Table 1. Continued.
factors, and coping Increased use of LO

processes related resulted in higher
to bereavement? levels of growth.
Bivariate correlation
outcomes suggest
SRG is related to
“individual resour-
ces, demographic
characteristics, sit-
uational factors of
loss, and coping
processes adopted
during early
bereavement”
(p. 469).
SRGS-SF outcomes
indicated bereaved
who anticipated
the death of his or
her spouse had
significantly higher
levels of SRG.
SRGS-SF outcomes
indicated SRG in
early bereavement
was independent of
grieving.
(continued)
Table 1. Continued.
Delespaux Attachment and Quantitative based on To what extent does 321 bereaved who Background Online questionnaire Zero-order correla-
et al. (2013) severity of grief: the DPM the appraisal and had lost a romantic Questionnaire of analyzed through tions between vari-
The mediating role oscillation process partner, who were Loss-Related zero-order corre- ables indicated
of negative mediate the influ- over 18 years of Variables lations among vari- bereaved with an
appraisal and ence of both anx- age Inventory of able, partial anxious attachment
inflexible coping ious and avoidant Traumatic Grief correlation to con- had more grief
attachments on (ITG) trol for anxious responses, while an
grief reactions? Experience in Close dimension, and avoidant attach-
Relationships mediational ment had fewer
(ECR) analyses. grief responses.
Appraisal of LO and Mediational analyses
RO stressors indicated appraisal
Grief coping ques- of stressors and
tionnaire (based on coping strategies
IDWL) mediated attach-
ment avoidance
and grief reactions.
Results suggest that a
greater attachment
to the deceased
may be more
strongly associated
with negative
appraisal of
bereavement
stressors.
Dunn (2015) Young widows’ grief: Cross-sectional, What relationship 232 widows between TRIG Online survey ana- Widows focused on
A study of personal Quantitative based exists between 18 and 55 years of Quality of Life (QOL) lyzed through fre- the past had more
and contextual on Erikson’s life- quality of life, age, within the first 5-point Likert Scale quency, linear grief, widows in
span theory of coping orientation, 5 years post loss. IDWL regressions, longer
(continued)
Table 1. Continued.
factors associated psychosocial devel- psychosocial bal- Inventory of scatterplots, and a relationships had
with conjugal loss opment and the ance, and grief in Psychosocial correlation matrix. less grief and
DPM young widowhood? Balance (early- stronger bonds as
What relationship to-middle adult demonstrated
exists between subscale) through linear
grief and young Sociodemographic regression.
widow’s sociode- data A correlational matrix
mographic charac- and regression
teristics? analysis indicated
How much unique identity, religiosity
variance in grief and social support
experienced by influenced grief
young widows is marginally.
explained by indi- Regression analysis
vidual predictors? indicated greater
LO coping was
linked with more
grief, while higher
QOL, identity, and
generativity were
linked with less
grief.
Financial stability pre-
dicted less grief.
Regression analysis
indicated intimacy
balance scores
were stronger pre-
dictors of grief than
LO scores.
(continued)
Table 1. Continued.
Gerrish et al. Exploring maternal Mixed methods based How is meaning- 13 bereaved mothers Hogan Grief Reaction Two semistructured Mothers had adaptive
(2014) grief: A mixed- on cognitive/ making described who had partici- Checklist (HGRC) interviews analyzed and complicated
methods investiga- trauma theories, for bereaved pated in cancer Posttraumatic through interpreta- grief responses,
tion of mothers’ constructivist the- mothers’ adaptive support groups at Growth Inventory tive phenomeno- with most having
responses to the ories, and DPM and complicated some point (PTGI) logical analysis with adaptive ongoing
death of a child grief in response to Biographical Grid reference to DPM bonds with her
with cancer the death of a child Method model, biographical child within one,
to cancer? grid model. two or three of the
Descriptive statistics data analyses.
for analysis of Maladaptive beliefs
HGRC and PTGI. held prior to child’s
Integrated data death were
analysis strengthened, and
some had negative
changes in percep-
tion of self/others
as determined
through integrated
analysis.
Mothers had positive
personal changes as
determined
through integrated
analysis.
Majority had both
positive and nega-
tive meaning
reconstructions
based on thematic
(continued)
Table 1. Continued.
analysis.
Mothers identified LO
and RO coping
skills, and still used
coping skills
despite a significant
amount of time
since the child’s
death based on
thematic analysis.
Knowles and Coping flexibility, for- Quantitative based on Do trauma focus and 106 bereaved spouses Perceived Ability to Online survey ana- Regression analysis
O’Connor ward focus and DPM and the forward focus or life partners, Cope with Trauma lyzed through mul- indicated forward-
(2015) trauma focus in Perceived Ability to coping strategies ranging 65 to 80 (PACT) tiple regression focused coping
older widows and Cope Scale and flexibility, years, within the TRaumatic Grief eval- resulted in lower
widowers cross-sectionally first 3 years post uation of Response grief severity,
impact the severity loss to Loss (TRGR2L) which also lowered
of spousal grief? Yearning in Situations levels of yearning,
of Loss scale for loneliness, and per-
bereavement (YSL- ceived stress in
Bereaved) early bereavement.
Perceived Stress Scale Regression analysis
UCLA Loneliness indicated use of
Scale forward focus
Length of coping and flexibili-
Bereavement ty is most impor-
Expectedness of Loss tant during early
bereavement.
Pai and Carr Do personality traits Quantitative based on Does personality 276 (210 bereaved Center for Measures taken at Ordinary least
(2010) moderate the the stress process moderate the and 87 married Epidemiologic 6 months, 18 squares regression
(continued)
Table 1. Continued.
effect of late-life model, the Big Five effects of late-life control) Studies Depression months, and 4 models indicated:
spousal loss on personality traits, spousal loss on Part of Changing Lives Scale (CES-D) years post loss Extraversion and con-
psychological and the DPM depression? of Older Couples Indication of fore- were analyzed scientiousness pro-
distress? Do distinctive aspects (CLOC) data set warning of spouse’s through descriptive vide some
of personality death through statistics, ordinary protective effects
buffer against dis- interview least squares for those who
tress differently for Big Five Personality regression with anticipated the
sudden vs. antici- Scale Bonferroni correc- death.
pated spousal Symptom Checklist tion, and multivari- Extroversion and
death? 90 ate analysis. conscientiousness
Do secondary stres- did not impact
sors partially adjustment for
explain the effects those who experi-
of personality and enced sudden
widowhood on death.
depressive Extroversion helped
symptoms? with adapting when
the bereaved had at
least 6 months to
anticipate the
death.
(continued)
Table 1. Continued.
Richardson A dual process model Prospective two-stage Replicated Richardson 104 widowers and LO and RO variables Measures taken at 6 Outcomes indicate
(2006) of grief counseling probability based and Balaswamy’s 492 widows based on DPM months, 18 bereaved engage in
on the DPM study, with use of a Part of CLOC data model. months, and 4 LO and RO coping.
longitudinal sample, set Bradburn’s Affect years post loss. Regression analysis
research question Balance Scale (ABS) indicated religion
(s) were not and social support
indicated. are protective
factors.
Regression analysis
outcomes suggest
that clinicians need
to help bereaved
differ between
constructive and
destructive grief
activities to manage
the negative effects
of rumination.
(continued)
Table 1. Continued.
Richardson Coping with bereave- Mixed Methods based What factors best 200 widowed men Loss-orientation Interviews with open Multiple and linear
and ment among elder- on the DPM explain widowers’ during second year measures and closed regression
Balaswamy ly widowers adjustments during of bereavement Reinvestment questions. indicated:
(2001) the second year of Orientation Closed questions ana- Men widowed less
bereavement? variables lyzed through mul- than 500 days had
Bradburn’s ABS tiple and linear significantly more
Positive and Negative regression analysis. negative affect and
Affect Scale lower well-being
(PANAS) than those wid-
owed 500 days or
more.
LO and RO strategies
are important for
adaptive coping.
LO used more during
early stages and
influenced negative
affect.
RO was beneficial
later in bereave-
ment and signifi-
cantly impacted
positive affect.
Ruminating resulted in
more negative
affect.
Deaths occurring in
the hospital
resulted in
increased negative
affect, while deaths
in the home
resulted in less
negative affect.
(continued)
Table 1. Continued.
Meij et al. Parents grieving the Longitudinal based on What relationship 219 couples who had Dual Coping Measures taken 6, Correlations indicated
(2008) loss of their child: the DPM exists between experienced the Inventory (DCI) 13, and 20 months negative adjust-
Interdependence in parent coping death of a child Depressive Subscale post loss ment was pre-
coping strategies and of the Symptom Actor Partner dicted by LO, while
those of his or her Checklist-90 Interdependence RO related to
partner, in the (SCL-90) Model of analysis better adjustment.
parents’ adjust- Inventory of with multi-level Correlations indicated
ment process? Complicated Grief regression analysis high levels of RO
Does adjustment (ICG) protected against
differ by gender? high level of LO
Do LO and RO coping related to depres-
have an additional sion.
effect on parents’ Correlations indicat-
psychological ed men’s coping
adjustment? strategies are
related to their
female partner’s
coping. Both gen-
ders use RO
coping.
Unable to determine
if oscillation
between LO and
RO occurred.
LO ¼ loss-oriented; RO ¼ restoration-oriented; ANOVA ¼ analysis of variance; UCLA ¼ University of California, Los Angeles.
Fiore 23
coping process. As seen in Table 1 and Figure 5, study outcomes can be related
back to both LO and RO coping, while oscillation remains to be the component
that is least “visual” in the coping process and in the existing research. Linear
regression indicated maladaptive coping strategies of LO coping can been seen
through by the bereaved focusing on the past (Dunn, 2015) and by having an
anxious attachment to the deceased as seen through zero-order correlations
(Delespaux et al., 2013). In addition, integrated analysis indicated maladaptive
Loss-Oriented (LO)
Bereaved who ruminated about the loss had

more negative affect (Richardson & Rumination/wishful
Balaswamy, 2001). thinking
Deaths occurring in the hospital resulted in

greater negative affect (Richardson &
Balaswamy, 2001). Negative event
interpretation
Maladaptive beliefs held prior to child’s
death were strengthened, and some mothers
had negative changes in perception of self
and others (Gerrish et al., 2014).
LO is related to negative psychological

Intrusion of grief
adjustment (Meij et al., 2008).
Denial/avoidance of
LO coping is not significantly related to restoration changes
stress-related growth (Caserta et al., 2009).
Widows who focused on the past had higher

Negative reappraisal
levels of grief, with LO coping having a
Grief work
significant negative relationship with higher
grief levels (Dunn, 2015).
Bereaved with an anxious attachment to the

deceased experienced more grief responses
(Delespaux et al., 2013). Grief work
Increased use of LO coping resulted in

higher levels of stress related growth
(Caserta et al., 2009).
Bereaved who anticipated spousal death had

significantly higher levels of stress related
growth (Caserta et al., 2009).
Meaning reconstruction
Majority of mothers had both positive and
negative meaning reconstructions (Gerrish
et al., 2014).
Figure 5. Included study outcomes applied to the DPM.

Loss-Oriented (LO) continued
Negative effects of rumination suggest

clinicians need to help bereaved differ Intrusion of grief,
between constructive and destructive grief Rumination
activities (Richardson, 2006).
LO coping influenced negative affect more

and was more important during early
bereavement (Richardson & Balaswamy, Experience pain of grief
2001).
Negative adjustment was predicted by LO

coping (Meij et al., 2008).
Restoration-Oriented (RO)
Positive reappraisal
RO has greater benefits later in bereavement
(Richardson & Balaswamy, 2001).
All mothers had reported positive personal Expressing positive affect

changes (Gerrish et al., 2014).
RO increases positive affect. Bereaved <500

days had more negative affect than bereaved Positive event interpretation,
>500 days. (Richardson & Balaswamy, 2001) Expressing positive affect
Deaths occurring in the home resulted in less
negative affect (Richardson & Balaswamy,
2001).
Distraction from grief,
Religion and social support are protective Doing new things,
factors (Richardson, 2006). Religion was a New roles/identities and
protective factor (Caserta et al., 2009). relationships
RO coping shows better adjustment to the
loss. Men use more RO coping than women,
and men whose female partners used more Distraction from grief and
RO coping were better able to adjust to the
loss of a child (Meij et al., 2008). Attending to life changes
20% of stress related growth occurs 2-6 mo.

post-loss, and is significantly related to RO Develop new roles, identities,
coping (Caserta et al., 2009). and relationships
Bereaved with an avoidant attachment to the
deceased experience fewer grief responses,
Denial/avoidance
and may use more confrontation and
avoidance coping (Delespaux et al., 2013). of grief
Figure 5. Continued.
Fiore 25
Restoration-Oriented (RO) continued

Develop new roles, identities
All mothers had adaptive and complicated and relationships
grief responses, with most having adaptive
ongoing bonds with her child (Gerrish et al.,
2014).
RO coping was strongly related to stress Meaning re-construction

related growth (Caserta et al., 2009).
Majority of mothers had both positive and

negative meaning reconstructions (Gerrish
et al., 2014).
RO was directly related to level of self-care,

daily living skills, and personal growth
(Caserta & Lund, 2007). Attending to Life Changes,
Distraction from Grief
Forward focus coping led to less severe grief,
yearning, loneliness, and perceived stress
(Knowles & O’Connor, 2015).
Widows in longer relationships had stronger

bonds and less grief. Greater use of LO Accept Reality of
coping was linked with higher levels of grief, Changed World
while greater QOL, identity, and generativity
predicted less grief (Dunn, 2015).
RO coping related better to adjustment,

protecting against high levels of LO related
depression (Meij et al., 2008).
Mediating Variables in Bereavement
Financial stability predicted lower levels of grief (Dunn, 2015).
Intimacy balance scores within the Inventory of Psychosocial Balance (IPB) were stronger predictors of
grief than LOS scores (Dunn, 2015).
Extraversion and conscientiousness provide some protective effects for those who anticipated death (at
least 6 months), but did not impact adjustment for those who experienced a sudden death (Pai & Carr,
2010).
Appraisal of stressors and coping strategies mediated attachment avoidance and grief reactions
(Meij et al., 2008).
Stress related growth is related to “individual resources, demographic characteristics, situational factors
related to loss, and coping processes adopted during early bereavement” (Caserta et al., 2009, p. 469).
Deaths occurring in the hospital resulted in increased negative affect, while deaths in the home resulted
in less negative affect (Richardson & Balaswamy, 2001).
Figure 5. Continued.
beliefs held by the bereaved prior to the death can be strengthened, which can
lead to the bereaved having negative changes in perception of self or others
(Gerrish et al., 2014). Hierarchical regression analyses showed that bereaved
who use high levels of LO coping and low levels of RO coping exhibit higher
levels of depression and loneliness (Caserta & Lund 2007), as linear regression
demonstrated that LO coping influences negative affect (Richardson &
Balaswamy, 2001). Correlations from the Actor Partner Independence Model
indicated greater use of LO coping led to maladaptive coping (Meij et al., 2008).
Regression analysis showed that adaptive RO coping strategies can be seen
through the bereaved engaging in forward focus coping, which can improve
coping flexibility (Knowles & O’Connor, 2015). Bereaved who use high levels
of RO and low levels of LO have better coping efficacy to deal with death as
measured by the IDWL (Caserta & Lund, 2007), while linear regression indi-
cated RO coping significantly impacted positive affect (Richardson &
Balaswamy, 2001). In addition, RO coping correlated to stress-related growth
(SRG), with higher levels of SRG occurring when the bereaved anticipated the
death for at least 6 months and were able to engage in RO coping prior to
bereavement (Caserta et al., 2009). RO coping was also related to the bereaved’s
ability to engage in self-care, daily living skills, and overall personal growth as
measured by the 23-item scale for perceived skills for self-care and daily living
tasks (Caserta & Lund, 2007). One ongoing challenge with RO coping is that it
is a difficult concept for bereaved to understand and see how he or she is engag-
ing in RO coping. Clear identification of the concept is needed to help bereaved
understand and ultimately engage or further engage in RO coping (Caserta &
Lund, 2007).
Although some outcomes clearly relate to either LO or RO coping, some
study outcomes identified protective factors or mediating variables that impact-
ed the bereavement process. An ordinary least squares regression models indi-
cated that when bereaved had 6 months to anticipate the death, the personality
traits of extraversion and conscientiousness positively impacted the bereavement
process (Pai & Carr, 2010). Conflicting outcomes were found for the potential of
social support and religion to be protective factors. Although the outcomes for
both Richardson (2006) and Caserta et al. (2009) found social support and
religion to be protective factors for bereaved over the age of 65 and 50, respec-
tively, Dunn (2015) reported that the bereaved spouse’s identity, religiosity, and
social support had little impact on the level of grief experienced for those aged
18 to 55 years. Mediating variables include financial stability, length of relation-
ship, location of the death, appraisal of stressors, partner’s coping strategies,
and the potential for SRG. Dunn’s (2015) correlational matrix and regression
analysis reported that financial stability at the time of bereavement and the
length of relationship with the deceased predicted lower levels of grief, as
bereaved who were in longer relationships had stronger bonds. Linear regression
denoted that the location of the death impacted the bereaved’s affect with deaths
Fiore 27
occurring in the hospital resulting in more negative affect and deaths occurring
in the home resulting in less negative affect (Richardson & Balaswamy, 2001).
Related to attachment to the deceased, mediational analyses showed that the
bereaved’s appraisal of stressors and the use of his or her coping strategies
mediated attachment avoidance and grief reactions (Delespaux et al., 2013).
Specifically for men, Meij et al. (2008) found correlations that men’s coping
strategies were directly related to their female partner’s coping, with women
using more RO coping resulted in lower levels of depression for the men.
Finally, a bivariate correlation showed that the bereaved’s potential for SRG
was related to “individual resources, demographic characteristics, situational
factors related to loss, and coping processes adopted during early bereavement”
(Caserta et al., 2009, p. 469), with anticipation of the death also being a key
factor.
Are Interventions Based on the DPM More Effective for Bereaved Adults to
Achieve Adaptive Coping Compared to Traditional Grief Therapy for Grief,
Stress, and Coping?
Twelve studies examined the effectiveness of interventions based on the DPM
framework (Caserta et al., 2014; Holtslander et al., 2016; Lund et al., 2010;
MacKinnon et al., 2015; Marshak, 2015; McGuinness, Finucane, & Roberts,
2015; K. Shear, Frank, Houck, & Reynolds, 2005; M. K. Shear et al., 2014;
Ryckebosch-Dayez, Zech, Mac Cord, & Taverne, 2016; Supiano & Luptak,
2013; Wittenberg-Lyles et al., 2015; Zuckoff et al., 2006) and are summarized
in Table 2. Study types included two randomized longitudinal studies from the
LAL data set, one 2-cell prospective randomized controlled clinical trial, one
quantitative, one randomized controlled trial (RCT), one quantitative 2 by 4
prospective RCT, four mixed-methods, one mixed-methods RCT, and one fea-
sibility multimethod RCT. Results indicate that interventions based upon the
DPM may be more effective than traditional grief therapy. Although many of
the intervention studies below indicate significant positive outcome differences
between DPM-based interventions and the compared intervention, results were
not consistent across all studies.
A systematic evaluation of the included studies’ quality was difficult to assess
between studies. The 12 included studies used 26 different measures, with five
measures being used in two or three studies, and the remainder of the measures
being used in only one study. The IDWL and Beck’s Depression Inventory were
used in three studies, while the Clinical Global Improvement Scale (CGIS),
Inventory of Complicated Grief (ICG), and the Hogan Grief Reaction
Checklist (HGRC) were used in at least two studies. Another challenge in eval-
uating study quality related to the lack of consistent indication of sufficient
power. Of the 12 included studies, one included a power analysis (Supiano &
Luptak, 2013), one planned for a 15% attrition rate (M. K. Shear et al., 2014),
Table 2. Included Studies Investigating the Effectiveness of Interventions Based Upon the DPM.
Caserta et al. Coping processes among Randomized; longitudinal Can a DPM-based inter- 328 recently bereaved Inventory of Daily 14 weekly sessions Everyone increased use
(2014) bereaved spouses based on the dual vention influence over 50 years of age, Widowed Life Comparison group of RO coping, though
process model (DPM) coping processes dif- 2 to 6 months post (IDWL) (n ¼ 143) all LO- comparison group
ferently than a tradi- loss, and followed based interventions had a greater change.
tional support group? over a year Treatment Group Oscillation scores did
Are participants in the Part of Life After Loss (n ¼ 185) seven LO not vary greatly
DPM group more data and seven RO (alter- between groups.
readily able to oscil- nate weekly) Women had a slightly
late between LO and significant increase in
RO coping compared RO coping.
to the comparison Younger people used
group? more LO coping at
baseline and became
aware of RO coping
more quickly.
Lund et al. Experiences and early Randomized; longitudinal How are LO and RO 298 bereaved women Self-administered ques- Traditional grief therapy DPM group had more
(2010) coping of bereaved based on the DPM coping processes and men, over 50 tionnaire (background group (n ¼ 128) frequent use of RO
spouses/partners in enhanced by partici- years of age, 2 to 6 information and DPM-based intervention coping initially, and
an intervention based pating in both DPM months post loss bereavement meas- group (n ¼ 170) later both groups
on the dual process treatment group Part of Life After Loss ures) improved at similar
model (DPM) versus the compari- data IDWL Oscillation score levels.
son group? Both groups had a high
level of satisfaction.
DPM had similar level of
improvement with six
less LO sessions.
RO may be more effec-
tive if delivered indi-
vidually instead of
within a group.
(continued)
Table 2. Continued.
Shear et al. Treatment of complicat- Two-cell, prospective, How does the efficacy of 83 women and 12 men Clinical Global Interpersonal psycho- Both treatments had
(2005) ed grief: A random- RCT based on the a novel approach to with complicated Improvement Scale therapy (IPT; n ¼ 46) fewer complicated
ized controlled trial DPM complicated grief grief, ages 18 to 85 (CGIS) Complicated grief thera- grief symptoms,
treatment compare to years Hamilton Rating Scale for py (CGT; n ¼ 49) though response rate
standard Anxiety and 16 sessions with average was better for CGT
psychotherapy? Depression (HRSD) of 19 weeks (51%) than IPT (28%).
Structured clinical inter- participation A more specific inter-
views vention is needed for
Medical screening complicated grief.
evaluation
Zuckoff et al. Treating complicated Quantitative based on Is an adapted version of 16 adults (mean Inventory of Manualized, 24 individual Significant decreases in
(2006) grief and substance Shear et al. (2005), CGT effective for age ¼ 42.3 years) with Complicated Grief sessions over 6 complicated grief and
use disorders: A pilot which was based on bereaved who abuse complicated grief and (ICG) months, using an significant increases in
study DPM, though did not or are substance substance depen- Beck Depression adapted CGT proto- substance abstinence
specifically state dependent? dence/abuse, at least Inventory col for substance use with use of adapted
framework 6 months post loss Time Followback (TLFB) behavior, guided by CGT protocol.
DPM.
Shear et al. Treatment of complicat- RCT based on Does complicated grief 151 bereaved, aged 50 Structured Clinical CGT informed by DPM CG improved for both
(2014) ed grief in elderly Attachment Theory treatment (CGT) years or older, and Interview for DSM-IV or IPT for 16 weekly groups, though CGT
persons: A random- and the DPM result in greater scoring at least 30 on Axis I Disorders with sessions had a significant
ized clinical trial improvement in CG Inventory of supplemental module change in symptom
and depressive symp- Complicated Grief for CG reduction compared
toms than grief- Columbia Suicide to IPT group who
focused IPT? Severity Rating Scale were moderately ill at
CG-focused CGI-I end of treatment.
Beck Depression
Inventory
Supiano and Complicated grief in Quantitative, 2 4 pro- Is CGT (Shear et al., 34 bereaved, aged 60 Prolonged Grief TAU—8-week protocol Participants in both
Luptak older adults: A ran- spective RCT based 2005) provided as years or older, at least Disorder Scale (PG- adapted to 16 weeks groups significantly
(2014) domized controlled on Attachment group therapy (com- 6 months post loss of 13) CGGT—16 week proto- improved PG-13
trial of complicated Theory and the DPM plicated grief group significant family Brief Grief Questionnaire col adapted from scores, with CGGT
grief therapy therapy [CGGT]) member (BGQ) Shear’s Complicated having significantly
more effective than Clinical Global improved.
(continued)
Table 2. Continued.
standard group thera- Impressions Scale Grief: A Guidebook 100% of CGGT partici-
py (treatment as usual (CGI) for Therapists pants score 5 or
[TAU]) for older Beck Depression below on BGQ com-
adults with compli- Inventory pared to 25% of TAU
cated grief? Beck Anxiety Inventory participants
Mini-Cog screen Both groups had
Suicide Risk decreased anxiety,
though CGGT groups
change was significant
CGGT group made con-
sistent improvement
while TAU group
varied with less over-
all gains.
DPM is appropriate for
studying CG and
normal grief.
MacKinnon et al. A pilot study of meaning- Mixed Method based on How do bereaved indi- 11 bereaved adults over Revised Grief Experience 12-session meaning- Majority of bereaved
(2015) based group counsel- meaning making, the viduals respond to 18 years, with loss Inventory (RGEI) based group counsel- found the meaning-
ing for bereavement DPM, and brief group meaning-based group occurring between Core Bereavement Items ing (MacKinnon et al., based intervention
psychotherapy counseling? 6 weeks and 2 years (CBI) 2015) beneficial.
Hogan Grief Reaction Meaning and anxiety
Checklist (HGRC) measures remained
Center for Epidemiologic almost unchanged
Studies Depression pre- to postinterven-
Scale (CES-D) tion.
Purpose in Life Test (PIL) Possible increase in CBI
Grief and Meaning- score and HGRC
Reconstruction subscales of despair/
Inventory (GMRI) disorganization.
Integration of Stressful Sample size too small to
Life Experiences Scale run statistical tests.
(ISLES)
Question about psycho-
tropic regimen.
(continued)
Table 2. Continued.
Marshak (2015) DBT and bereavement: A Mixed Methods, Does the timing of 29 bereaved, aged 18 to Brief C.O.P.E. Scale 5 weeks, 45-minute Participants used skills
multiple baseline Interpretive, implementing DBT, or 85 years, enrolled in Global Emotion Scale modified DBT diary taught through DBT
design Nonconcurrent mul- DBT at all, improve the General Adult Diary entries (hope and form intervention, intervention though
tiple baseline based coping outcomes? Loss Group fear), rate core skills with staggered inter- there was no statisti-
on Attachment Six groups, with two each day on a 3-point vention start points. cal difference among
theory, the DPM, control groups and scale, describe dis- Diary explained core participants’ experi-
continuing bonds, four intervention tress tolerance, mind- skills and coping enced emotions and
postpositivism, and groups fulness, emotion strategies for grieving. the time frame for
DBT regulation, and inter- intervention imple-
personal effectiveness mentation.
Participants in the DBT
intervention had a
significant level of love
emotion.
When the intervention
was provided later,
statistically significant
levels of denial were
experienced.
Ryckebosch- Daily life stressors and Mixed Methods based on What is the frequency 40 widowed people, ages 10-point Likert scale for Diary entries for 7 days, Stressors related to
Dayez et al. coping strategies the DPM and types of LO and 57 to 83 years distress, with z-scores analyzed through the- spousal death were
(2016) during widowhood: A RO bereavement- used to calculate matic analysis most frequent 1 year
diary study after 1 related stressors and Relative Level of later.
year of bereavement coping strategies wid- Distress (RLD) and Specific coping strategies
owed people experi- Relative Coping were identified and
ence over 1 week? Efficacy (RCE) perceived as effective
for dealing with the
stressor.
Groups of stressors and
associated coping
strategies for manag-
ing stressors were
related to specific
(continued)
Table 2. Continued.
times during the day.

Behavioral coping was
used a majority of the
time, with cognitive
being the next most
used, and affective
coping being the least
used.
Holtslander Developing and pilot- Multi Method, Feasibility What is the feasibility of 19 older bereaved adults Demographic and infor- Finding Balance FBI validated emotions
et al. (2016) testing a Finding RCT based on the a psychosocially sup- with a mean age of 72 mation about Intervention (FBI) and provided ways to
Balance Intervention DPM portive writing inter- years, and loss being deceased based on the DPM find balance and ben-
for older adult vention focused on within 28 months due Herth Hope Index (HHI) efit during bereave-
bereaved family care- finding balance for to advanced cancer HGRC ment.
givers: A randomized older adult bereaved IDWL Found FBI beneficial and
feasibility trial family caregivers of Qualitative Open-ended easy to use, and
advanced cancer Evaluation Questions enjoyed writing about
patients? personal experiences.
Oscillation scores
increased for FBI
group while control
group’s decreased.
Statistically significant
increase in RO coping
for FBI group.
Wittenberg- “It is the ‘starting over’ Mixed Method based on Can a secret Facebook 16 bereaved caregivers Patient Health Guidelines for appropri- Majority of online posts
Lyles et al. part that is so hard”: the DPM group developed to with a mean age of Questionnaire ate participation and were RO focused,
(2015) Using an online group provide bereavement 48.6 years (PHQ-9) education information which elicited feelings
to support hospice information and sup- Generalized Anxiety were provided. of loss.
bereavement port improve the Disorder Screening Discussion questions LO was shared through
consequences of the Tool (GAD-7) facilitated group storytelling, sharing/
bereavement discussion. giving advice, and
experience? encouraging others
(continued)
Table 2. Continued.
on how to manage
their coping.
LO stressors triggered
by sudden statements,
and feelings or
expressions that were
not anticipated.
McGuinness A hospice-based Mixed-Methods RCT Is a custom designed 20 bereaved adults, ages Adult Attitude to Grief Creative arts bereave- Both groups gained in
et al. (2015) bereavement support based on the DPM, creative arts program 32 to 75 years (AAG) ment group based on ability to oscillate
group using creative and Drama therapy for bereavement sup- Texas Revised Inventory DPM for eight ses- between LO and RO
arts: An exploratory concept of varying port effective for of Grief (TRIG) sions in closed-group coping
study therapeutic distance adults? Open-ended questions format Participants in the art
to gather views and group who attended
experiences six or more sessions
had significantly dif-
ferent AAG scores.
Both groups experienced
decreased grief inten-
sity, with the Arts
group having a non-
significant change
between Time 1 and
Time 2, and the wait-
list control group
between Time 2 and
Time 3.
LO ¼ loss-oriented; RO ¼ restoration-oriented; RCT ¼ randomized controlled trial.

two studies indicated a probability for insufficient power (Caserta et al., 2014;
Lund et al., 2010), and one study indicated insufficient power (K. Shear et al.,
2005). Finally, not all of the participants in the intervention studies had com-
plicated grief. Four of the 12 intervention studies were for complicated grief (K.
Shear et al., 2005; M. K. Shear et al., 2014; Supiano & Luptak, 2013; Zuckoff
et al., 2006), while 2 studies included participants with uncomplicated or com-
plicated grief (Lund et al., 2010; Marshak, 2015), and the remainder of the
studies were for uncomplicated grief.
Living After Loss Intervention Studies

Caserta et al. (2014) and Lund et al. (2010) use the “Living After Loss” (LAL)
data set. The LAL study compared traditional grief therapy to a DPM inter-
vention delivered over 14 weeks for participants who were 2 to 6 months post
loss. Those in the DPM group intentionally alternated between LO and RO
coping, and experienced the oscillation process through the presented topics.
Participants in the DPM group used more RO coping initially, but later both
treatment groups increased use of RO coping at a similar rate. Caserta et al.
(2014) found a high amount of RO coping in both the DPM and the traditional
grief therapy groups. Participants in the traditional grief therapy group
increased their use of RO coping at a faster rate than the DPM group.
Researchers hypothesized that participants in the traditional grief group had
posed questions related to RO coping, as well as the possibility that family and
friends were supporting their use of RO coping despite it not being the focus of
the group. Participants in both groups were more aware of their LO coping than
RO coping, due to participants identifying RO coping later when they were
more familiar with the concept (Caserta et al., 2014). Furthermore, oscillation
scores did not vary greatly between the DPM and traditional grief therapy
group as both groups used high levels of both coping styles. RO coping sessions
were delivered in a group setting which may have impacted their effectiveness, as
participants later expressed varied needs pertaining to learning new skills. RO
sessions may be more effective when presented individually to meet each per-
son’s individual needs related to his or her bereavement experience. Overall, the
intervention did not affect the oscillation process, which researchers felt could be
related to the need for individually presented RO interventions. Further
research on intervention dosage in the bereavement process is needed.
Complicated Grief Therapy Intervention Studies

A randomized controlled clinical trial (K. Shear et al., 2005) compared a 16-
session Complicated Grief Therapy (CGT) intervention which described the
DPM during the introductory stage of therapy and included LO and RO com-
ponents into the middle phase of therapy, to a standard interpersonal
Fiore 35
psychotherapy (IPT) intervention, for participants who were 6 months or more

post loss. Both interventions resulted in decreased complicated grief symptoms,
though the CGT intervention yielded a greater response (51%) than the IPT
intervention (28%). A later study comparing the CGT intervention informed
by the DPM to IPT delivered weekly for 16 weeks resulted in CG scores improv-
ing for both groups, though the CGT group had a significant reduction in symp-
toms compared to the IPT group. In addition, participants in the IPT group were
still classified as moderately ill at the end of 16 weeks of treatment (M. K. Shear
et al., 2014). Zuckoff et al. (2006) used a manualized 24-individual session CGT
protocol based on the DPM that was adapted for use with bereaved individuals
diagnosed with substance abuse. The intervention delivered over 6 months
resulted in significant decreases in both complicated grief and substance use.
Although the previous CGT studies were delivered individually, an adapted
version of the CGT 16-week protocol (K. Shear et al., 2005) for use with groups
was developed and tested. Supiano and Luptak (2013) used the adapted proto-
col to compare a Complicated Grief Group Therapy (CGGT) protocol to stan-
dard group therapy with bereaved older adults. Although both groups’ scores
improved on the Prolonged Grief Disorder Scale (PG-13) and had decreased
anxiety, the CGGT had significant improvements on the PG-13 and significantly
less anxiety. In addition, all CGGT participants scored a five or below on the
Brief Grief Questionnaire compared to only 25% of the standard group therapy
participants. Overall, participants in the CGGT group made consistent progress
over the 16 weeks, while participants in the standard group therapy group had
varied improvements across weeks with fewer overall gains.
Intervention Studies Using Other Approaches

Beyond the LAL and complicated grief intervention studies, several individual
studies examined interventions using approaches such as meaning making, writ-
ing, online bereavement groups, and arts-based bereavement groups.
Meaning-making intervention. An adapted version of Meaning-Based Group

Counseling (MBGC) 12-session protocol manualized by MacKinnon et al.
(2015) was used to examine the impact on bereaved individuals’ grief and
coping. Due to the sample size being small overall (n ¼ 12) and the quantitative
data set being even smaller (n ¼ 9), statistical analysis was not possible.
Descriptive evaluation indicated that measures for meaning and anxiety
remained basically unchanged, with a possible increase in participants’ scores
on the Core Bereavement Items and submeasures of despair and disorganization
within the HGRC. Researchers noted that the qualitative data indicated most
participants found the MBGC protocol beneficial (MacKinnon et al., 2015).
Writing interventions. A multiple baseline design compared a modified Dialectical

Brief Therapy (DBT) protocol to standard bereavement therapy used with par-
ticipants in General Adult Loss groups. The modified DBT intervention con-
sisted of five diary entries related to an introduction to DBT skills, mindfulness,
distress tolerance, emotion regulation, and interpersonal skills. Diary entries
were completed after each 45-minute DBT session (five total) within 8 weeks
of bereavement care. Results indicated the use of DBT skills increased over time
for all groups, indicating that familiarity with skills was more crucial than the
timing of the delivery. In addition, when looking at the Global Emotion Scale,
participants in the DBT groups had statistically significant ratings for love and
also statistically significant ratings for denial when groups were started during
Weeks 6 and 8 (Marshak, 2015).
A later study examined the use of diary entries across 7 days to determine older
bereaved adults LO and RO stressors and the participants associated coping
strategies relative to their level of distress and coping efficacy (Ryckebosch-
Dayez et al., 2016). Results indicated that participants 1-year post loss experi-
enced RO stressors primarily in the morning and afternoon and associated the
stressors with low levels of distress. RO stressors were most often coped with
through the use of behavioral confrontation. LO stressors were more commonly
experienced during the evening and night and were associated with high levels of
distress. LO stressors were either coped with through time passing with no coping
strategies used or behavioral avoidant coping strategies.
A Finding Balance Intervention (FBI) based on the DPM for older bereaved
adults contained written prompts to journal over a 2-week period that was
followed-up with open-ended questions presented during an RN visit. The jour-
nal prompts related to “walking a fine line” (oscillation component), “deep
grieving” (LO coping), and “moving forward” (RO coping). Outcomes indicated
that participants in the FBI group increased oscillation scores compared to the
control group having decreased oscillation scores. The FBI group also had sta-
tistically significant increase in the RO coping (Holtslander et al., 2016).
Online bereavement groups. In response to the growing social media trend, a mixed-
methods study employed an undisclosed Facebook (FB) group using a DPM
framework for bereaved hospice caregivers. Within the 9-month FB group, par-
ticipants from three hospices were given guidelines for participation, psychoedu-
cational information, and discussion questions to prompt group engagement.
Analysis of FB posts indicated that a majority were RO focused, which led to
feelings of loss. LO coping was shared through telling his or her story, sharing/
giving advice, and encouraging others to cope (Wittenberg-Lyles et al., 2015).
Art-based interventions. A bereavement group based on the DPM consisting of

psychoeducational information and creative arts approaches was offered in a
closed-group format across eight sessions and compared to a traditional
Fiore 37
bereavement group. Each arts-based session had a different theme with the
intention to have the bereaved engage in his or her bereavement through varying
distances (near to far). Results indicated that both groups improved in their
ability to oscillate between LO and RO coping. Both groups experienced
decreased grief intensity, though it occurred earlier for individuals in the arts-
based group. Adult Attitude to Grief (AAG) scores were not impacted statisti-
cally significant by the intervention, except for those participants who engaged
in at least six of the eight sessions (McGuinness et al., 2015).
Strengths of the current systematic review include the use of two groups of
three people each in addition to the researcher to provide multiple, independent
reviews; use of an article review procedure; and eligibility checklist to increase
validity and diminish the risk for bias.
Discussion
The research included in this systematic review indicates that the DPM of
coping represents the bereavement experience, and the interventions based
upon the DPM may be effective for treatment of grief, stress and coping.
Despite positive support, more research is needed to understand both the
model and how interventions based on the DPM impact the bereavement
process.
Areas for Further Investigation

Oscillation. Since the development of the DPM, the IDWL, and the Dual Coping
Inventory (DCI) measures have been created to test this model. The IDWL
developed by Caserta and Lund (2007) measures the three components of the
DPM (LO, RO, and oscillation). The IDWL consists of 22 items (11 of each of
LO and RO) rated on a four-point scale. The oscillation balance score is calcu-
lated by subtracting the LO score from the RO score. As oscillation is a complex
phenomenon, further research is needed to more objectively measure this oscil-
lation process during bereavement. A year later the development of the IDWL,
the DCI was developed by Meij et al. (2008) and was theoretically based on the
DPM to measure both LO and RO coping for bereaved parents. The measure
includes three LO items and four RO items, rated on a 5-point scale. The estab-
lishment of measures to specifically evaluate the DPM and the effect of inter-
ventions based on the DPM indicates a level of acceptance for the model among
clinicians and researchers and a desire for evidence-based practice.
The oscillation process between LO and RO coping is difficult to comprehend
and measure and requires further investigation to better conceptualize the pro-
cess and understand how and when it occurs during bereavement to achieve
adaptive coping. Oscillation, the most complex component of the DPM poses a
research challenge as it is not easily understood or measured due to the variance
of stressors over time. M. Stroebe and Schut (2010) suggested ways to further
examine and understand the oscillation process, through the use of both labo-
ratory and clinical settings. The studies included in this review measured oscil-
lation by subtracting the LO score from the RO score, as indicated in the IDWL
measure. Delespaux et al. (2013) concluded that oscillation needs to be mea-
sured more objectively in order to see interruptions in the oscillation process
that indicate the possibility of maladaptive coping. Caserta and Lund (2007)
concluded with six areas for further understanding to include (a) the optimal
balance and timing of interventions; (b) clearer articulation of the balance
(number) of LO and RO coping, and if an equal balance is optimal; (c) an
understanding of the depth of bereaved’s oscillation and engagement in both
LO and RO coping; (d) the frequency of oscillation, which may be best under-
stood through qualitative research; (e) the extant to which bereaved individuals
are aware of oscillating and their ability to control when oscillation occurs; and
(f) bereaved individuals motivation to oscillate between coping styles. Finally,
Meij et al. (2008) was unable to determine if oscillation occurred, indicating
further development is needed to specifically understand oscillation.
To more clearly measure and understand oscillation, the use of ecological
momentary assessments (EMAs) should be considered for inclusion in study
design. EMAs provide real-time assessment of participants daily lives (ecological
component) to measure participants’ current state (momentary component) at
predetermined times that can occur over a period of time (Shiffman, Stone, &
Hufford, 2008). EMA data decrease the potential for recall bias since data col-
lection occurs in the moment and can include multiple methods such as “paper
and pencil, palm-top computers, or telephones” (Shiffman et al., 2008, p. 5).
A potential challenge for using EMA data to measure oscillation is determining
the optimal resolution frequency for data collection within a given day to
account for oscillation in the moment. Since oscillation does not have a distinct
behavior to observe, time-based sampling would need to be used instead of event
sampling, though a combination of time and event sampling may also be con-
sidered in order to obtain antecedent information prior to oscillation which
could help identify maladaptive coping responses. Although there could be
the potential for impact reactivity (e.g., the behavior being impacted simply
due to being observed), the potential should be low due to oscillation being a
discreet behavior that bereaved are initially less aware of in daily life as indicated
in the above presented research. Due to oscillation being the least understood
component for bereaved, an event diary related to oscillation may also be dif-
ficult for participants to complete and could be subject to recall bias if partic-
ipants were asked to recall behaviors or emotions over a period of time.
Although sampling necessitates a high level of participant compliance in order
to capture accurate data of the oscillation phenomenon, consideration for par-
ticipant burden needs to be accounted for when determining the optimal sam-
pling rate. Finally, the use of EMA data collection will require the researcher(s)
Fiore 39
to examine if the time frames of existing self-report assessments will transfer to

EMA sampling based on the existing instructions of the assessment (Shiffman
et al., 2008).
Intervention delivery. Components of intervention delivery that need further defi-

nition relate to the overall content of the interventions, the population(s) who
would benefit the most from intervention, as well as optimal dosage needed to
effect positive changes in coping. The outcomes from Ryckebosch-Dayez et al.
(2016) indicated that behavioral interventions were used most frequently by
older bereaved individuals, compared to occasional use of cognitive strategies
and minimal use of affective coping. Behaviorally based coping strategies and
interventions make the transition from LO to RO coping most evident as an
action is completed to prompt the change in coping style. In addition,
Ryckebosch-Dayez et al. (2016) found that RO stressors were most commonly
addressed through behavioral confrontation while LO stressors used more
behavioral avoidance. Although these results illustrate how older adults cope
with bereavement, additional research is needed to determine if this is consistent
for bereaved from other age groups.
Bereaved participants’ ability to understand RO coping and then integrate
RO coping strategies is needed to further improve delivery intervention.
Although bereaved were actually engaged in RO coping, participants did not
necessarily perceive their skills and engagement as RO coping due to limited
awareness of the concept (Caserta et al., 2014). In addition to bereaved needing
a greater understanding of what constitutes RO coping, bereaved also need a
variety of RO session content, with some RO content possibly being better
addressed through individual sessions instead of a group format. The use of a
needs assessment for bereaved participants to identify RO coping needs prior to
treatment delivery could identify both topics as well as if the identified topic(s)
would be best addressed through group or individual therapy. Replication stud-
ies with individual RO sessions are needed to see if a tailored RO session design
results in a significant increase in adaptive coping over the course of treatment.
Giving participants the option of different individual RO sessions specific to
their needs allows participants to practice independent decision-making skills,
which is a component of Caserta et al.’s 14-week DPM-based intervention pro-
tocol. In regard to the development of the IDWL measure, refinement needs to
minimize any inadvertent overlaps between LO and RO coping based on how
statements are presented, clarification of RO activities, and also to have partic-
ipants report RO activities instead of feelings (Caserta & Lund, 2007).
The existing research has begun to identify the population(s) who will benefit
the most from complicated grief intervention. Providing intervention for a pop-
ulation with high grief scores may also increase participants’ engagement in the
RO session content outlined by Lund et al. (2010) since the topics may be more
relevant. Information about a person’s general health, financial stability,
education, level of depression, length of marriage, location of the death (home

vs. hospital), if the death was anticipated, individual grief response (normal vs.
complicated), and the length of time elapsed between the death of spouse and
intervention delivery need to be considered. These mediating factors provide
insight into an individual’s predictive mental health, ability to actively cope,
and perceived competence in engaging in RO coping when taking on new
roles that include his or her spouse’s daily tasks. Providing intervention
during the first year for people who have less education (academic and life
experience), limited financial resources, lower personal health status, and limited
time to anticipate the loved one’s approaching death may be most beneficial for
helping manage complicated grief symptoms. Future research needs to account
for these variables and test the efficacy of the DPM with subsequent studies
using a participant sample with complicated grief as they are more likely to seek
and benefit from treatment. This would also account for diverse individual
factors that could impact participants’ intervention responses.
The dosage of group-based interventions varied between 8 and 14 weeks,
involving five studies. Results of the McGuinness et al. (2015) demonstrated
the impact for positive changes in AAG scale when participants attended at
least six of the eight provided. Although the LAL intervention consisted of
14 weekly sessions with 6.5 sessions dedicated to RO coping, participants com-
mented that some of the RO sessions were distracting to the overall process since
the content did not relate to all individuals. Participants also suggest that less
time could be spent on RO coping, which could relate to the overall number of
sessions. Similarly, Caserta et al. (2014) concluded that an ideal balance between
LO and RO sessions still needs to be determined.
Limitations
It is possible that relevant articles were missed in the current systematic review.
The search terms for this review were kept narrow to limit identification of other
dual-process models developed outside of the bereavement context. In the
future, reviews could include more diverse search terms to account for the
DPM being utilized and tested with more diverse populations. As the recogni-
tion for the DPM increases as a viable model for coping with varied losses, more
quantitative studies will be conducted which will precipitate the potential need
for a broader review of the DPM in the future. Also, since qualitative studies
were excluded to limit the scale of the current review, another review should be
completed to integrate the outcomes of the qualitative studies with this system-
atic review to provide a more well-rounded review of the DPM. The 22 studies
included in this review used 47 different measures, making it difficult to objec-
tively evaluate effectiveness between studies. Small samples or samples not being
representative of the larger national sample impact the ability to generalize the
results of the included studies. Finally, effect size and power were not
Fiore 41
consistently reported across studies making the evaluation of the quality of

research difficult. It should also be noted that the relationship to the deceased
varied among the studies, though for the purpose of this review, relationship
was limited to a significant relationship (i.e., spouse, significant other, child).
Additional Research Published After Systematic Review Inclusion Dates

Due to the complexity and time required to conduct a systematic review, the date
range of 1999 through June 30, 2016 was established. Research about the DPM
has continued to be published beyond the date range indicated in this systematic
review. Central to the DPM, M. Stroebe and Schut (2016) published an update to
the DPM including a consideration of overload and how excessive stressors expe-
rienced during bereavement in both LO and RO coping can be too much for
bereaved to handle. This overload experience can help explain the high levels of
mental and physical health problems bereaved experience. In addition to the
updated concept of overload, Albuquerque et al. (2017) conducted a longitudinal
study examining parents’ coping flexibility and meaning-made after the death of a
child. Also in 2017, Brodbeck, Berger, and Znoj conducted a 10-week RCT using
an Internet-based self-help intervention based on the task model of mourning and
the DPM for older adults dealing with bereavement, separation, or divorce. The
intervention design used a novel approach of text-based sessions lasting 45 to
60 minutes with e-mail support from psychologists. Finally, Lundorff, Thomsen,
Damkier, and O’Connor (2019) conducted a prospective study over 7 months to
exam levels of LO/RO coping and how LO/RO coping changes across time.
Five additional studies about the DPM were conducted with nonwestern par-
ticipants, which provide an important extension of the model to other cultures. Li
and Chen (2016) tested a Social Support in Bereavement model that relates to the
DPM with a Chinese population which further delineates components for: LO and
RO-Emotional, LO and RO-Instrumental, and LO and RO-Information. The
authors also provided cultural guidance for how to implement social support
with the Chinese population. In the following year, Tang and Chow (2017)
conducted semistructured interviews in Hong Kong to test the DPM in a non-
western culture, while Nam (2017) conducted an intervention study in South
Korea looking at how RO coping impacts self-care in bereavement. Chen, Fu,
Sha, Chan, and Chow (2017) conducted DPM informed in-depth interviews over
2 years to explore mothers’ bereavement as an outcome of the 2008 earthquake in
China. Finally, Chow et al. (2018) conducted a cluster-RCT comparing a 7-week
Dual-Process Bereavement Group Intervention-Chinese (DPBGI-C) to a LO
Bereavement Group Intervention (LOBGI) measuring complicated grief, anxiety,
depression, loneliness, and social support, with follow-up at 16 weeks. Although it
is possible that other studies published between July 2016 and September 2019 may
also support the DPM and DPM-based interventions, the studies included in this
section were most evident in the updated literature search.
Implications for Practice

Researchers and clinicians can use the outcomes of this systematic review to
further expand the DPM intervention research base. The DPM provides a real-
istic framework to illustrate the bereavement experience as it accounts for mul-
tiple bereavement stressors occurring simultaneously, and the use of
confrontation and avoidance behaviors as part of the bereavement experience.
Clinicians can use this information to work on refining established protocols
based on the DPM, determining optimal dosage, and incorporating a variety of
intervention approaches to meet the varied needs of bereaved individuals.
Refinements should address the areas of the model that need further research
such as the oscillation process, how to make the RO component best function
for the bereaved relative to both content and delivery approach (individual vs.
group), and how to incorporate research of the model in a more moment to
moment experience for more reliable data. Group participants could also be
given a needs assessment before beginning sessions for facilitators to know his or
her specific RO needs in order to tailor the sessions to the group needs. This
would also allow facilitators to evaluate whether RO session components would
be more effectively delivered in a group or individual setting based on content.
In addition, examination of the cross-cultural extension is needed to determine if
cultural differences are a mediating variable in the coping process, with meas-
ures and interventions being adapted to fit the cultural norms beyond western
cultures. Together, researchers and clinicians could collaborate to further test
both the model, interventions based on the model, determine the impact of
mediating variables, and the optimal time since the death occurred to initiate
treatment in order to maximize intervention effectiveness.
Acknowledgments
The author would like to thank Dr. Deanna Hanson-Abromeit for her guidance with this
project. The author also thanks the following students for their assistance in coding
articles for this systematic review: Kelsey Adriance, MT-BC, Amy Diffenderfer, Anna
Leestma, Cameron Pumfrey, Jordan Walsh, and Taylor Woods. The author greatly
appreciates the time and dedication that the students gave to this project.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.
Fiore 43
ORCID iD
Jennifer Fiore https://orcid.org/0000-0002-1764-0421
Supplemental Material
Supplemental material for this article is available online.
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Author Biography
Jennifer Fiore has been an assistant professor of Music Therapy at Western
Michigan University since 2015. She holds a Bachelors (emphasis in Music
Therapy) and Masters in Music Education (emphasis in Music Therapy), and
a doctorate of Philosophy in Music Education (emphasis in Music Therapy)
from the University of Kansas. Jennifer has over 10 years of clinical experience
working with both pediatric and adult patients in hospice and palliative care,
bereavement camps, oncology, and older adults. Jennifer is a consistent present-
er at the local, regional, and national level. Her research interests include
bereavement, hospice and palliative care, oncology, and stress and coping.

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Article

OMEGA—Journal of Death and Dying

A Systematic Review of the Dual Process Model of Coping

The DPM of Coping With Bereavement

Figure 1. Dual Process Model of Coping with Bereavement (1999).

Figure 3. Dual Process Model of Coping with Bereavement-Revised (2015).

1. Does the DPM accurately represent the bereavement experience for a

Assessed for Excluded (n=214)

Abstracts screened Excluded (n=174)

Figure 4. PRISMA flow diagram. LO ¼ loss-oriented; RO ¼ restoration-oriented;

Does the DPM Accurately Represent the Bereavement Experience for

High LO levels and

factors, and coping Increased use of LO

Bereaved who ruminated about the loss had

Deaths occurring in the hospital resulted in

LO is related to negative psychological

Widows who focused on the past had higher

Bereaved with an anxious attachment to the

Increased use of LO coping resulted in

Bereaved who anticipated spousal death had

Figure 5. Included study outcomes applied to the DPM.

Loss-Oriented (LO) continued

Negative effects of rumination suggest

LO coping influenced negative affect more

Negative adjustment was predicted by LO

All mothers had reported positive personal Expressing positive affect

RO increases positive affect. Bereaved <500

20% of stress related growth occurs 2-6 mo.

Restoration-Oriented (RO) continued

RO coping was strongly related to stress Meaning re-construction

Majority of mothers had both positive and

RO was directly related to level of self-care,

Widows in longer relationships had stronger

RO coping related better to adjustment,

Mediating Variables in Bereavement

Financial stability predicted lower levels of grief (Dunn, 2015).

times during the day.

LO ¼ loss-oriented; RO ¼ restoration-oriented; RCT ¼ randomized controlled trial.

Living After Loss Intervention Studies

Complicated Grief Therapy Intervention Studies

psychotherapy (IPT) intervention, for participants who were 6 months or more

Intervention Studies Using Other Approaches

Meaning-making intervention. An adapted version of Meaning-Based Group

Writing interventions. A multiple baseline design compared a modified Dialectical

Art-based interventions. A bereavement group based on the DPM consisting of

Areas for Further Investigation

to examine if the time frames of existing self-report assessments will transfer to

Intervention delivery. Components of intervention delivery that need further defi-

education, level of depression, length of marriage, location of the death (home

consistently reported across studies making the evaluation of the quality of

Additional Research Published After Systematic Review Inclusion Dates

Implications for Practice

Declaration of Conflicting Interests

Horowitz, M. (1986). Stress response syndromes. Northvale, NJ: Aronson.

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