Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated grief and their child’s mental health

1 THIS MANUSCRIPT IS CURRENTLY UNDER REVIEW Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated grief and their child’s mental health Na Zhang1, Irwin Sandler2, Jenn-Yun Tein2, Sharlene Wolchik2, and Erin Donohue3 Department of Human Development and Family Sciences, University of Connecticut REACH Institute, Department of Psychology, Arizona State University Psychology Department, College of Saint Benedict and Saint John’s University Author Note: Correspondence concerning this article should be addressed to Na Zhang, University of Connecticut, University Place, Stamford, CT 06901 Email: nazhang@uconn.edu Acknowledgment: The study was funded by a grant from New York Life Foundation to Irwin Sandler Na Zhang’s work on this paper was supported by a National Research Service Award in Primary Prevention by the National Institute on Drug Abuse T32DA039772 (PI: Laurie Chassin) through the REACH Institute, Department of Psychology, at Arizona State University Jenn-Yun Tein’s work was supported by grants from the National Institute on Drug Abuse (2R01DA09757) Jenn-Yun Tein’s and Sharlene Wolchik’s work was also supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD094334) A portion of this work was presented at the 2020 meeting of the Mind and Life Institute Contemplative Research Conference which was held virtually Abstract Self-compassion, which involves mindfulness, self-kindness, and common humanity, has been found to be related to individuals’ mental health Few studies have examined caregivers’ selfcompassion in relation to parenting behaviors or child adjustment in addition to its relation their own mental health Objectives: In the current study we examined caregivers’ self-compassion as a protective factor related to parentally bereaved children’s internalizing and externalizing problems We further tested whether the relations were mediated by caregivers’ parenting practices or complicated grief (i.e., persistent severe grief reactions that impair normal functioning) Methods: The sample consists of caregivers who participated in an intervention study for bereaved families and reported high levels of complicated grief At T1 (baseline) and T2 (20 weeks later), caregivers completed surveys on demographic information, selfcompassion, complicated grief, parental warmth and consistent discipline, as well as child internalizing and externalizing problems Results: Findings supported that caregivers’ selfcompassion was prospectively related to decreased internalizing and externalizing problems in bereaved children The effect of self-compassion on externalizing problems was mediated by parental warmth and consistent discipline Self-compassion was also prospectively associated with decreased complicated grief and psychological distress, although complicated grief and psychological distress were not related to child outcomes Conclusions: These findings add to the knowledge on the psychological benefits of self-compassion for both bereaved children and their caregivers Key words: self-compassion; parenting; complicated grief; internalizing problem; externalizing problems Direct and indirect effects of bereaved caregivers’ self-compassion on their complicated grief and their child’s mental health In the United States, over two million children have experienced the death of a parent (Weaver, 2019) Parental death confers risk for multiple short- and long-term mental and physical health as well as social problems Parental death during childhood is associated with poor psychological outcomes in bereaved children including depression, anxiety, conduct disorder, low self-esteem, social withdrawal, as well as alcohol and substance abuse (Brent et al., 2009; Hamdan et al., 2012; Kaplow et al., 2010; Worden & Silverman, 1996) About one fifth of children who experience parental health experience serious psychological problems (Dowdney, 2000; Worden & Silverman, 1996) A study based on a nationwide cohort sample from three Nordic countries found that parental death before the age of 18 was associated with a 50% increased all-cause mortality in early adulthood (Li et al., 2014) Although parental death elevates risk, not all parentally bereaved children experience significant problems Research on risk or protective factors can help identify subgroups who may be more or less likely to show problem outcomes The extant literature suggests that children who lost a parent at a younger age, whose parent died from external causes (e.g., suicide, homicide, accident versus illness), who lost a mother (versus a father), and whose family background is disadvantaged are at higher risk for poor outcomes (Appel et al., 2013; Berg et al., 2016; Brent et al., 2009) In addition, caregivers play a critical role in children’s post-loss adjustment There is a growing literature that shows that parenting practices predict parentally bereaved children’s adjustment (Haine et al., 2006; Howell et al., 2016; Kwok et al., 2005; Lin et al., 2004; Saldinger et al., 2004; Tein et al., 2006) In addition, some evidence suggests that caregivers’ mental health problems, such as depression or psychological distress were related to bereaved children’s outcomes (Cerel et al., 2006; Kwok et al., 2005) In the Family Stress Model (Masarik & Conger, 2017), stressful circumstances are posited to increase parental psychological distress, which influences child adjustment problems through disrupted parenting Jiao et al (2020)’s conceptual framework recognized that bereaved parents face multiple challenges in providing an environment for the healthy development of their bereaved children while dealing with their grief and multiple stressors after the death This framework highlights the role that parent-child relationships play in children’s post-death outcomes and the interdependence of parent’s and children’s adjustment outcomes The current study focused on a malleable protective factor, caregivers’ self-compassion Although the concept is understudied in bereaved families, self-compassion may have important implications for parent-child relationships and both the children’s and caregivers’ adjustment outcomes after the death Self-compassion is an inner rather than outer resource that caregivers can rely on while dealing with their challenges It may be difficult for parents to nurture this resource given that caregivers are often advised to take a child-centered approach to parenting after the death (Saldinger et al., 2004) and as a result they may prioritize family care over selfcare Below, we discuss the literature and our hypothesized model to test how caregivers’ selfcompassion relates to parenting, complicated grief, psychological distress and children’s outcomes What is Self-compassion? Neff (2003a) proposed that self-compassion is a dynamic balance between three intertwined aspects: mindfulness (versus overidentification), self-kindness (versus self- judgment), and common humanity (versus isolation) Specifically, mindfulness refers to the nonjudgmental awareness and acceptance of one’s experience, whereas overidentification refers to the state of being “fused” with one’s experience which can cause avoidance or rumination Self-kindness involves the caring and responding attitude toward oneself in the face of suffering, whereas self-judgment involves criticizing oneself for having flaws or making mistakes Finally, common humanity points to the understanding that all humans encounter difficulties in life and that one is not alone in their suffering, whereas isolation gives rise to feelings of disconnectedness and loneliness Self-compassion has been found to be a protective factor in many stressful situations (Leary et al., 2007) A meta-analysis of 14 studies, which included student samples, found large effects of self-compassion on psychological distress, such as depression, anxiety, and stress (MacBeth & Gumley, 2012) Self-compassion is malleable and can be enhanced through training A meta-analysis of 27 randomized, controlled trials of selfcompassion interventions found improvements in a range of psychological outcomes, including stress, depression, and anxiety, negative affect, and rumination (Ferrari et al., 2019) Self-compassion and Complicated Grief in Adults The death of a close family member can lead to psychological distress and a wide range of physical (e.g., dizziness, indigestion, pain) and mental health problems (e.g., depression, posttraumatic stress symptoms, substance use) (Stroebe, Schut, & Stroebe, 2007) While these responses abate over time for most individuals, about 10% of bereaved adults experience a range of significant emotional and behavioral impairments that either worsen or persist over a prolonged period of time, which is known as complicated grief (Shear et al., 2011) Normal grief and complicated grief differ by their severity and persistence over time (Holland et al., 2008) Complicated grief is distinguishable from other bereavement-related mental health problems, such as depression and anxiety (e.g Prigerson et al., 1996) There are several reasons why self-compassion may reduce complicated grief Wada and Park (2009) discussed how self-compassion may mitigate self-pity or self-criticism that interferes with adjustment to the death Self-compassion may also be related to adaptive emotion regulation that facilitates adaptive grief and reduces complicated grief (Maccallum & Bryant, 2013) Indeed, self-compassion has been found to be as effective as other adaptive emotion regulation strategies (i.e., cognitive appraisal and acceptance) in reducing depressed mood for adults with major depressive disorder (Diedrich et al., 2014) The elements of self-compassion mindfulness, self-kindness, and common humanity - may help bereaved people to see their griefrelated thoughts and emotions as impermanent mental events rather than parts of their selfidentify As a result, the use of maladaptive emotion regulation strategies linked to complicated grief, such as rumination or avoidance, may be reduced (Boelen et al., 2006; Eisma et al., 2014; Maccallum & Bryant, 2013) Although self-compassion appears to be an antidote to many of the complicated grief symptoms such as avoidance, distress, anger, troubling rumination, and inability to accept the death, little empirical evidence exists on the relation of self-compassion to complicated grief There is one cross-sectional study of family members of missing persons (about one third were parents whose child went missing) that found the self-compassion was significantly related to lower posttraumatic stress symptoms, depression, and complicated grief (Lenferink et al., 2017) Complicated Grief and Child Adjustment There is also scant research on the relation of caregivers’ complicated grief to child adjustment after the death Caregivers’ complicated grief could increase children’s internalizing and externalizing problems for several reasons First, parents with complicated grief may reflect underlying neurobiological vulnerabilities (e.g., Schultze-Florey et al., 2012) that could be inherited by their child Second, complicated grief could affect children’s emotion regulation the processes of “initiating, maintaining, and modulating the occurrence, intensity, and expression of emotions” (Morris et al., 2007, p 3), which is related to internalizing and externalizing problems (Eisenberg et al., 2001) In particular, parents with complicated grief may exhibit negative emotions that are linked to children’s negative emotions through parent-child bio-behavioral synchrony and moment-to-moment dynamics (Morris et al 2014) Finally, caregivers with complicated grief may unintentionally create a negative emotional climate in the family that can hinder child development (Morris et al., 2007) One qualitative study with spousally bereaved parents suggested that parents and children shared similar grief reactions and parents struggled to cope with grief in both themselves and their child (Bugge et al., 2014) The current study is the first quantitative examination of the associations between caregivers’ complicated grief and child internalizing and externalizing problems Self-compassion, Parenting, and Child Adjustment Problems Self-compassion may be related to parenting practices, as it is related to emotion regulation, a psychological determinant of parenting (Crandall et al., 2015) Nemati et al (2020) found that parents’ self-compassion was cross-sectionally associated with parental warmth in a sample of mothers of children with developmental disabilities Gouveia et al (2016) found that parental self-compassion was cross-sectionally associated with higher authoritative parenting and lower authoritarian/permissive parenting, and the associations were mediated by mindful parenting (i.e., bringing awareness and compassion to parent-child interactions) in a community sample of mothers and fathers of school-aged children in Portugal Finally, in a study of parents with a history of depression, Psychogiou et al (2016) found that mothers with higher selfcompassion used less critical comments when describing their preschoolers, and fathers reported less distress and more supportive reactions to their preschoolers who displayed negative emotions Although the stability of parenting was not controlled for, the study by Psychogiou et al (2016) represents the first longitudinal study in support of a prospective relation between parental self-compassion and parenting This study also showed that parental self-compassion was negatively associated with preschoolers’ internalizing and externalizing problems, but the associations became non-significant after controlling for the effects of covariates The current study extends this work by examining the prospective relations between caregivers’ selfcompassion and parenting, while controlling for the stability of parenting over time as well as possible confounders The Current Study The current study is the first to examine parental self-compassion as a protective factor for parentally bereaved families We used two-wave secondary data from a larger intervention study (for more details, see [MASKED FOR PEER REVIEW], 2021) All bereaved families were receiving services from bereavement agencies and intervention (service type) was controlled for in the analyses Based on the literature reviewed above, we hypothesized that caregivers’ self-compassion at baseline (T1) would be associated with lower child internalizing and externalizing problems 20 weeks later (T2) We further hypothesized mediation effects such that caregivers’ self-compassion at T1 (independent variable) would be associated with lower complicated grief, lower psychological distress, higher parental warmth, and higher consistent discipline (mediators) at T2, which in turn would be associated with lower child internalizing and externalizing problems (dependent variables) at T2 METHOD Participants A total of 74 caregivers (female = 78.4%) participated in the study They were on average 43.8 years (SD = 7.95, Range 26~65) and primarily non-Hispanic (82.4%) and White (64.9%), with 21% being African American, 4.1% Asian American, 2.7% multi-races and 6.8% other races Their education levels were high school (13.5%), some college (9.5%), diploma or certificate beyond high school (10.8%), associate degree (10.8), Bachelor’s degree (29.7%), Master’s degree (21.6%), or doctorate degree (4.1%) Their children’s age averaged 10.58 years old (SD = 3.67, Range [3~17]);52.7% were female Relative to the bereaved child, the caregivers were: parent (87.7%), adopted or stepparent (4.1%), grandparent (4.1%), other family relatives (4.1%) The deceased parent was their husband (45.9%), wife (14.9%), ex-husband (6.8%), ex-wife (2.7%), non-married partner (14.9%), or other family members (17.5%) The death occurred an average of 20.5 months prior to the study (SD = 16.4; Range = ~80) The most frequent cause of death was illness (heart disease [21.6%], cancer [24.3%], and other types of illness [24.3%]), followed by accident (10.9%), homicide (8.1%), and suicide (9.5%) Procedure Data were drawn from a project that evaluated a community-based program for bereaved families in which caregivers were recruited at four agencies in four states in the United States These agencies regularly provided bereavement support services to either the bereaved children, 10 caregivers or both Eligibility criteria were: death occurred more than three months prior to the beginning of the study; caregiver had at least one child (