INTRODUCTION

In the experience of most humans, the death of a beloved next of kin is an extremely upsetting and stressful life event to which people may develop somatic, cognitive, emotional, or behavioral responses. These reactions, a natural element of the grieving process, are found to continue over time with decreasing intensity (1,2). A significant section of the population is able to regain their functionality over time, adapt to change, and continue with their daily lives despite the severity of the loss. It is also known that some people are unable to adapt and their symptoms after loss do not decrease, leading to a chronic grieving process (3,4). Chronification of grief can prevent people from dealing with their day-to-day chores and lead to a loss of physical and psychological wellbeing (3-5).

There are numerous studies investigating why some people readapt to their everyday lives after completing the process of grief while others develop a chronic presentation (2,6). Those studies found certain risk factors for the chronification of the grieving process (e.g., traumatic circumstances of loss, the loss being unexpected, losing a young person, as well as individual characteristics and the psychiatric history of the bereaved person). The relevant literature emphasizes particularly the reconstruction of meaning as one of the most important factors for the chronification of the grieving process (7-9).

Giving Meaning to Loss

According to Janoff-Bulman (10), human beings entertain a number of assumptions about themselves, the world, and other people. Those assumptions are based on the expectation that we are at least to some degree relevant, the world is predictable and safe, and other humans are good and helpful. Janoff-Bulman asserts that these assumptions are of greatest importance for the sustainability of everyday life. Similarly, Park states that each person possesses an inherent world of meaning (11). According to Park, everyone has beliefs about themselves, their future, and the world. People’s perception of their purposes, roles, and their place in the world constitutes their personal world of meaning. Thoughts about justice, goodness, or faith create meaning for the world. Expectations and predictions of future events give meaning to the future. As Park says, people perceive all their life events by placing them within this world of meaning. The unexpected death of a beloved person can shake or even demolish a person’s world of meaning and the related assumptions (10,12). As a traumatic experience, the death of a beloved next of kin can profoundly upset a person, as it does not have a place in his or her world of meaning. The bereaved person may feel help- and powerless, see the world as unpredictable and unjust, and feel hopeless in the face of a dark future (10-13). For a person to get over the grieving process and tune back into to the rhythm of their daily life, the reconstruction of their world of meaning is considered necessary (7-9).

Gillies and Neimeyer reported three main factors for the reconstruction of meaning after a loss, the first of which they describe as “sense making,” corresponding to the bereaved person’s struggle to understand why the death happened and why their beloved relative rather than any other person died (7,8). In the sense-making process, the bereaved finds an explanation or a reason for the death. The second factor in the process of reconstructing meaning is called “benefit finding,” defined as the ability to see some light of hope in life despite the disruptiveness and negativity of death. This may include elements such as changing priorities in life, being closer to family members, acknowledging help from other people and one’s own importance, or making plans to reorganize one’s life (9,12). Finally, the last factor is “identity change,” which includes an ability to understand the value of certain things better after a low, creating closer relationships with other people, overcome procrastination, discover new roles in life, and becoming a more empathetic person.

Several studies identify the reconstruction of meaning after a loss as a protective factor against chronic grief (8,9,14). E.g., a longitudinal study by Davis et al. (15) found that an increase in variables for reconstruction of meaning after loss correlated with a decrease of symptoms in the following months. Furthermore, there are numerous results affirming the efficacy of interventional studies aimed at the reconstruction of meaning in persons with symptoms of chronic grief (16).

Measuring the Reconstruction of Meaning

After Loss

Neimeyer (16) writes that until today, a significant number of studies measured the variable of reconstruction of meaning with a single, open-ended question that was analyzed qualitatively. He pointed out that a more detailed examination of the reconstruction of meaning, being one of the most important determinants for the grieving process, required the development of an instrument that was valid and reliable from the perspective of studying mediating and moderating variables and establishing relations with other variables.

The relevant literature includes three different quantitative measures for the reconstruction of meaning after loss. One of these is the Integration of Stressful Life Experiences Scale, assessing in how far people can integrate the event they have experienced into their world of meaning (17). Another scale is the Inventory of Complicated Spiritual Grief (18). It assesses in how far people are able to find meaning after loss through faith and spirituality. It has been shown that these two scales do not sufficiently reflect the multidimensional structure of the reconstruction of meaning and the width of thematic fields involved in finding meaning (16).
The Grief and Meaning Reconstruction Inventory (GMRI) developed by Gillies et al. (13) has helped overcoming these shortcomings regarding the multidimensional structure and the comprehensiveness of content, assessing the various ways of reconstructing meaning with an exhaustive, multidimensional instrument (13,16).

In addition to the instruments listed above, some other scales have been used to measure negative life events, including the Post-Traumatic Growth Inventory (PTGI) (19) and the Core Beliefs Inventory (CBI) (18). PTGI measures positive experiences after a traumatic life event, such as positive change in interpersonal relations, feeling of personal strength, change in spirituality, or discovery of new opportunities in and appreciation of life (19). Administration of the PTGI presupposes that the person has undergone a traumatic life event. By contrast, the GMRI used in our study has been developed specifically for losses caused by death and can be administered even when the death has not happened in a traumatic way. In addition, it also includes specific areas not found in the PTGI, such as emptiness and meaninglessness and continuing bonds with the deceased person. The CBI assesses in how far persons after a negative life event are questioning beliefs about themselves, other people and the world, the meaning of life, and faith. A higher CBI score indicates a high level of questioning basic beliefs that have been shaken (20). The GMRI measures in how far this shaken world of belief can be reconstructed. In comparison with other instruments in the relevant literature, the GMRI, while it can only be used after the death of a loved one, no matter if the loss was traumatic or not, allows to measure subdimensions not included in other instruments, which means that it has a high original value.

In the Turkish literature on loss and bereavement, we could not find any empirical studies or scales assessing the process of reconstructing meaning after loss. To improve this situation, our study adapts the GMRI to Turkish culture and analyzes the psychometric properties of the scale. Adapting an up-to-date instrument that is frequently used in loss and grief studies is an important contribution to the national literature and can also stimulate research into reconstruction of meaning in the context of emerging loss and grief studies in Turkey.

METHOD

For this study, convenient sampling was used to select 306 adults of the age range 18-65 years (mean=35, SD=11.3) who had lost mother, father, spouse, or a sibling due to death at least six months and at most ten years earlier. All participants volunteered to contribute to the study and signed a voluntary consent form. Ethics approval was received from the ethics committee of Hacettepe University.

Enrolled in the study were 234 women (76.5%) and 72 men (23.5%). Seventeen of the participants (5.6%) were primary school graduates, 6 (2.0%) had finished middle school, 64 (20.9%) high school, 110 (35.9%) had a university degree and 109 (35.6%) had completed postgraduate education. While 86.0% reported no psychiatric disorders, 14.0% had received treatment for conditions like depression or anxiety. During the past ten years, 235 of the participants (76.8%) had lost one relative, 71 of them (23.2%) more than one. The latter group completed the survey with regard to the loss that had affected them the most.

The age of the relatives that the participants had lost ranged from 15 to 90 years (mean=54.4, SD=17.2). The mean period elapsed since the loss for the whole sample was 42 months. Of the deceased relatives, 152 (49.7%) had died of cancer, 83 (27.1%) of heart attack or brain hemorrhage, 16 (5.2%) due to traffic accidents, 6 (2.0%) had committed suicide,
4 (1.3%) had been victims of occupational accidents, 4 (1.3%) of natural disasters, 4 (1.3%) of terror attacks, 2 (0.7%) of murder, and 35 (11.4%) had died naturally of old age.

Measures

Demographic Data Form: This form had been developed by the researchers; it contains questions about characteristics of the participants, the deceased persons, and circumstances of their loss.

Grief and Meaning Reconstruction Inventory (GMRI): The GMRI is a scale assessing if a person after a loss has been able to find new meaning in the world and if they learned from the loss, achieving personal growth and adaptation. The original form was developed by Gillies et al. (13). It consists of 29 items in 5 subdimensions, scored on a 5-point Likert-type scale. The subdimensions are “continuing bonds,” “personal growth,” “emptiness and meaninglessness,” “sense of peace,” and “valuing life.” Either the total score or scores from the subdimensions can be used. Items belonging to the emptiness and meaningless subscale (2, 6, 9, 16, 20, and 27) are reverse-scored.

The subdimension “continuing bonds” includes items 1, 5, 11, 14, 18, 21, and 26, “personal growth” items 3, 8, 13, 19, 22, 25, and 29, “sense of peace” items 7, 10, 15, 17, and 23, “emptiness and meaninglessness” 2, 6, 9, 16, 20, and 27, and “valuing life” items 4, 12, 24, and 28 (13). With increasing score, the level of reconstruction of meaning becomes higher. For the original scale, a test-retest reliability of 0.71 was found. The internal consistency coefficient for the total scale worked out at 0.84. For the subscales, the consistency coefficients ranged between 0.76 and 0.85. A correlation of -0.39 was found between the GMRI and the Complicated Grief Inventory and a correlation of -0.25 between the GMRI and the Behavior and Symptom Identification Scale (BASIS-32) (13).

Beck Depression Inventory (BDI): The BDI is an instrument consisting of 21 items scored on a 4-point Likert-type scale (0-3 points) assessing cognitive, emotional, and behavioral symptoms of depression. With increasing depression symptoms, the score on the scale rises. The original instrument was developed by Beck et al. (21). There are different versions of adaptations to Turkish culture. In our study, we used the version adapted by Tegin (22), which had a test-retest reliability of 0.65, a split-half reliability of 0.78, and an internal consistency coefficient of 0.80.

State-Trait Anxiety Inventory (STAI). The STAI consists of 40 items scored on a 4-point Likert-type scale. Of the items, 20 are measuring state anxiety and 20 trait anxiety. The higher the anxiety level, the higher is the score participants reach. The original instrument was developed by Spielberger et al. (23), an adaptation to Turkish culture was carried out by Oner and Le Compte (24).

Procedure

The required permission to adapt the GMRI to Turkish was obtained from the authors. Then the scale items were prepared using the translation/back-translation procedure (25). The translations were carried out by researchers with a doctorate in psychology who are proficient in both languages and a professional translator.

Participants were enrolled using a convenient sampling method via announcements on the internet and by e-mail looking for voluntary participants. The survey set was completed online by 196 respondents and on paper forms by 110 persons. For the online participants, factors like the duration of completing the survey, multiple participation from the same IP address, and avoiding multiple completion of the survey were assessed. The participants who were completing the survey with pen on paper, the forms were handed out and again collected in sealed envelopes. All participants filled in the survey in their own home environment.

In the evaluation, as a first step SPSS 18.0 (Statistical Package for Social Sciences) was used to carry out an exploratory factor analysis in order to establish the factor structure of the scale and the distribution of the items according to these factors. In the next step, the factor structure of the scale was examined using parallel analysis. Then internal consistency, convergent validity, and predictive validity analyses were carried out.

RESULTS

Determining the Factor Structure of GMRI

Principal component analysis using oblimin rotation was applied to determine the factor structure of the Turkish GMRI form and the location of the items within the factors. A Kaiser-Meyer-Olkin (KMO) value of 0.84 and the results of the Bartlett’s sphericity test ( χ 2 =3310, SD=41, p<0.001) showed that the collected data were suitable for exploratory factor analysis.

In order to determine the number of factors for the Turkish GMRI form, factors with an eigenvalue above 1 and elbows in the scree plot were examined. These two indicators suggested a 4-factor structure for the Turkish form (personal growth, emptiness and meaninglessness, continuing bonds, and sense of peace). The variance explained by this 4-factor structure was 50.0% (Table 1). Before deciding upon a 4-factor structure, parallel analysis was performed using the script developed by O’Connor (26). Eigenvalues obtained as a result of parallel analysis are compared with eigenvalues found by exploratory factor analysis. The result confirmed a 4-factor structure for the scale (Table 2).

When we look at Table 1, we notice that the continuous bonds coincide one-to-one with the items in the subdimensions. Items 4, 12, 24, and 28, which in the original scale made up the subdimension of valuing life, in the Turkish form were located in the subdimension personal growth. Assessing the content of these 4 items, themes that stand out are the understanding that life is short and valuable, greater importance given to family, or the realization of new opportunities. The literature on post-traumatic growth sees the emergence of this state as something that can be assessed as personal growth (27). Thus, considering the factor loadings and contents of these four items, we decided to unite them with the personal growth subdimension.

With the exception of items 3 and 7, items from the emptiness and meaningless and peace subdimensions coincided with those in the original scale. In the original GMRI, item 3 was in subscale “personal growth,” while 7 was in subscale “sense of peace”; in the Turkish form, both fell under the subscale “emptiness and meaninglessness” (Table 1). Regarding the factor loading, including these items under emptiness and meaninglessness seemed appropriate, but considering their content, it was seen that they clashed with the other items in this subscale in their meaning, and therefore we decided to remove them from the instrument.

Construct Validity of the GMRI

At this point, correlation values between the individual GMRI subscales and with the total GMRI scores were calculated. In addition, correlations between GMRI and BDI or STAI were considered (Table 2).

As we will see in Table 2, correlations between GMRI subdimensions and total score vary between 0.48 and 0.82. These values are consistent with the ones found in the original study introducing the scale. On the other hand, correlation coefficients between personal growth and emptiness and meaninglessness subscale, emptiness and meaninglessness and continuous bonds subscale, and continuous bonds and sense of peace subscales were found to be not significant. These findings, while showing similarity with the original study, indicate that the subscales of the instrument might evaluate different structures (13). The relevant literature specifies that sense-making or reconstructing meaning after a loss improves a person’s functionality and reduces their psychiatric symptoms (9,13). In line with this data, the Turkish version of the GMRI form showed a very high negative correlation with depression and anxiety scores (Table 2). In conclusion, the correlation values shown in Table 2 are adequate to demonstrate the construct validity of the Turkish GMRI form.

Predictive Validity

In order to confirm the predictive validity of the GMRI, two separate hierarchical regression analyses were carried out using depression and anxiety scores as predictor variable. In the first step, age of the lost person, education level, time elapsed since the loss, and age of the bereaved person were entered as demographic variables in these analyses. In the second step, the total GMRI score was entered.

In the hierarchical regression analysis using depression as the predictor variable, the demographic factors entered in the first step were seen to explain 10% of the change in depression score
(R 2 =0.10, F[4,298]=8.44, p<0.001). When entering the GMRI score into the equation in the second step, the variance explaining the depression score increased to 29% (R 2 =0.29, F change [1,297]=77.95, p<0.001). As we can see in table 3, after controlling for age of the bereaved person, level of education, timespan since loss, and age of the lost person, the GMRI score explains the depression score.

In the hierarchical regression analysis using the total STAI score as predictor variable, predictor variables as in Table 3 were entered in the 1 st and 2 nd step. The demographic factors entered in the first step explained 12% of the change in anxiety score (R 2 =0.12, F[4,298]=9.97, p<0.001). When entering the GMRI score into the equation in the second step, the variance explaining the depression score increased to 27% (R 2 =0.27, F change [1,297]=62.27, p<0.001). Thus, after controlling for age of the bereaved person, level of education, timespan since loss, and age of the person lost, the GMRI score predicted the anxiety score (Table 4).

Reliability

To establish the internal consistency for the overall GMRI form in Turkish and for the subscales, separate Cronbach’s alpha values were calculated. These analyses found internal consistency coefficients of 0.82 for the total scale, for the personal growth subscale 0.80, emptiness & meaninglessness 0.77, continuous bonds 0.77, and for the sense of peace subscale of 0.80. For the original instrument, these values varied between 0.76 and 0.80 (13). Thus, from the perspective of internal consistency values the Turkish form of the GMRI is highly consistent with the original form.

DISCUSSION

In this study, the adaptation of the GMRI for Turkish has been carried out, finding validity and reliability values to be similar to those of the original instrument.

Results of exploratory factor analysis and parallel analyses confirm for the Turkish form a structure with 27 items and 4 subdimensions. These subdimensions are continuous bonds, personal growth, emptiness & meaninglessness, and sense of peace. Subdimensions and item distribution show a great similarity between the original and the Turkish form. Exploratory factor analysis showed that the items in the continuous bonds subscale coincide one-to-one with the original scale. Similarly, personal growth, sense of peace, and emptiness & meaninglessness subscale items (with the exception of items 3 and 7) coincide with the original scale. The 3 rd item (Since this loss, I’m more self-reflective), which in the original scale was placed in the “personal growth” subdimension, and the 7 th item (I’ve been able to make sense of this loss) that was in the ‘sense of peace’ subdimension, in the Turkish form fell under the subdimension emptiness & meaninglessness. While it seemed statistically appropriate to include these two items under the emptiness & meaninglessness subdimension, they did not fit in with the content of the other items in this subdimension. The items in the emptiness & meaninglessness subdimension emphasized a feeling of emptiness, the inability to make sense of the loss or to find anything positive, or themes of meaninglessness. These topics do not at all chime with the statement in item 7, “I’ve been able to make sense of this loss.” A possible explanation may be that the content of this item was not fully understood in our culture. Similarly, the expression “Since this loss, I’m more self-reflective.” in item 3 does not quite fit in with the theme of emptiness & senselessness. The thoughts of a person after a loss need not be related with senselessness; rather, they may be more positive, reflecting development, which makes us think that this item might not really assess the structure of emptiness and meaninglessness. Again, a possible explanation may be that this item is not understandable in our culture. Savasir points out that adapting a scale is different from translating the form, given that from culture to culture, the meaning expressed in a given item may change, which may require the removal of some items in the adaptation process (22). In this sense, as items 3 and 7 were not suitable for the emptiness & meaninglessness themes, we assumed that they did not work in our culture and thus decided to remove them from the Turkish form.

Finally, items 4, 12, 24, and 28, which in the original scale were located in the subscale valuing life, in the Turkish form came under the personal growth subscale. It is striking to look at their content: realizing life to be short and valuable and knowing its value (items 12 and 28), valuing family more after a loss (item 4), living life to the fullest and trying to seize the day (item 24). When Tedeschi and Calhoun defined the concept of ‘post-traumatic growth,’ they stressed that people sometimes after a traumatic life event were better able to understand the value of life, changed their priorities in life, were keener on enjoying the present, and developed more positive relations with other people (19,27). Considering both this information and the factor loadings, we assumed that these items were more suitable to be included in the personal growth subscale.

The reliability of the Turkish GMRI form was tested calculating Cronbach’s alpha values. These analyses found reliability values between 0.77 and 0.82 for the entire measure and its subdimensions. Similar to these findings, for the original form reliability coefficients varied between 0.76 and 0.80 (13). This similarity in coefficients shows that the reliability of the Turkish form is comparable with the original version.

The Turkish GMRI form showed a high correlation with measuring instruments for depression and anxiety. In addition, when controlled for important predictors like timespan since loss, age of the bereaved person, level of education, and age of deceased person, the GMRI scores positively predicted both depression and anxiety scores. In the literature, there are many studies showing a negative correlation between reconstruction of meaning after loss and symptom scales. Thus, our results support the construct validity of the GMRI.

One of the basic limitations of this study is the time since loss. In our study, the mean period elapsed since the loss was 42 months. The process of a person’s reconstruction of his or her assumptions and world of meaning after a loss can be observed more intensely in the first months or years after the event. With the passing of time, other life events may affect the process of sense-making. Another limitation is the indiscriminate inclusion of adults having lost mother, father, a sibling, or their spouse in the sample, as the relation with the lost person may affect the reconstruction of meaning after the loss. Similarly, the sense-making process may be different depending on if the person was lost in an accident or due to a sudden/violent death or if the death had been more predictable. It will be useful for subsequent studies to assess the process of reconstruction of meaning according to the mode of loss and the relation between bereaved and deceased person in samples with a shorter period since loss. Finally, one limitation may be that the study was carried out in a cross-sectional format based on self-reporting.

This study has shown that the Turkish adaptation of the GMRI, which had been developed to assess constructs in grieving persons such as giving meaning to loss, seeing a light of hope in life, or achieving personal growth through positive change in personality, has psychometric properties similar to those of the original form and can be used in our culture as a valid and reliable measuring instrument. This study has also confirmed that reconstruction of meaning after a loss is closely correlated to a reduction in psychiatric symptoms and reintegration of the person into everyday life. Therefore, we can say that it is very important for research as well as for clinical applications to have introduced a measure to our culture that can be used to establish if persons having suffered a loss are in a process of adaptation.

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