Eye-tracking and visual attention to loss-related stimuli in bereaved individuals

The loss of a loved one is among the most stressful life-events that a person
can experience. Although most people adjust to bereavement without professional
intervention, some people develop complications in their grieving process
and/or physical and mental health problems. Research has shown that ruminative
thought may be one of the central factors that influence bereavement outcomes
negatively. Rumination in grief consists of repetitive thoughts about the
events leading up to the loss, reasons why the loss occurred and the emotional
and physical consequences of the loss. Higher rumination in bereaved
individuals has been related to lower experienced well-being, and higher
depression and anxiety. Although the negative effects of rumination during
grief have generally been well documented, it is unclear what the function of
rumination is. Most researchers today think it is a confrontation strategy.
They believe bereaved individuals confront themselves repeatedly with the
reality of the loss, and through repeated exposure gradually come to terms with
the loss. However, this interpretation has called into question. Some
researchers now hold rumination may be similar to avoidance. According to this
interpretation, bereaved individuals think repeatedly about reasons for the
loss and why the loss occurred in order not to think about the reality of the
loss. As such, rumination disrupts and prolongs the grieving process. The
current study aims to clarify whether grief rumination is confrontation or
avoidance of the reality of the loss through the study of attention.

The study of attention is a broadly accepted and rigorous method for the study
of avoidance and confrontation. Eye tracking is the current state-of-the-art
method to assess attention patterns (for an example in a different field: Rinck
& Becker, 2006). In this study, the time-pattern of attention of bereaved
individuals for specific loss-related stimuli will be assessed for the first
time using two eye tracking tasks. We expect self-reported rumination to
predict a fearful avoidant pattern of attention (see also: Mogg et al., 2004)
in bereaved individuals, that is, the higher bereaved individuals score on
rumination, the stronger they will show initial vigilance and subsequent
avoidance for fear-relevant stimuli (i.e. loss-related stimuli).

The primary objective of the study is to determine whether people scoring
higher on grief rumination show a stronger vigilance-avoidance pattern of
attention for loss-related stimuli. We expect grief rumination will show a
positive linear relationship with the dwell time on loss-related stimuli on a
subconscious level (< 500 ms), which indicates initial vigilance. We expect a
negative linear relationship with dwell time on specific loss-related stimuli
on a conscious level (>500 ms-10.000ms), which indicates subsequent avoidance.

The study is a within subjects experimental study, which consists of four
phases. In the first phase, participants complete six questionnaires
(respectively on background information, depression, complicated grief,
posttraumatic stress, (depressive) rumination and rumination in grief). In the
second phase, participants complete two eye tracking tasks. In the third phase,
participants complete two memory tasks; a recall task and a recognition task.
In the last phase, participants will complete an emotional judgment task.
Before the first phase each participant will complete an informed consent
procedure and after phase four each participant will be debriefed. The complete
procedure will take approximately one hour for each participant.

Participants are asked to watch pictures of their deceased loved one and
pictures of an unknown person (matched on age, environment and sex) for five
minutes. These pictures will be combined with loss-related words (e.g. grief,
loss), neutral words (e.g. middle, globe) and negative words (e.g. failure,
angry). Participants are also asked to watch different types of words
(loss-related, neutral, negative) for approximately 5 minutes.

Exposure to loss-related stimuli, a central aspect of this study, may be
considered intrusive. However, the decision to use these stimuli in this study
is not taken lightly. Importantly, procedures used in this study have been
successfully applied numerous times in previous research on bereavement and
even trauma, without adverse consequences for participants. To reduce the
chance of adverse emotional reactions even further, people who have lost a
loved one recently, that is, less than six months ago, are excluded from the
study. While the adverse consequences for participants are expected to be low,
the scientific and clinical relevance of the research is very high, as insight
into avoidance mechanisms in bereaved individuals is crucial for the
understanding of development and persistence of complications in the grieving
process. Furthermore, the results of this study may give direction to future
research and to the development of psychological interventions for bereaved
individuals. That is, if rumination is confrontation, therapeutic interventions
should focus more on distraction, whereas if rumination is avoidance,
therapeutic interventions should focus more on confrontation (for details:
Chapter 8.3 of the protocol).