The Inventory of Complicated Spiritual Grief: Assessing Spiritual Crisis following Loss

Following the death of a loved one, many grievers endorse spirituality as a source of both solace and strain. Studies show that some grievers struggle significantly with both their relationship with God and their faith community, a condition known as complicated spiritual grief (CSG). However, researchers have lacked a simple, multidimensional, well-validated, grief-specific measure of CSG. In this brief report, we reviewed the psychometric validation process and clinical utility of a measure called the Inventory of Complicated Spiritual Grief (ICSG), which was tested with 304 Christian grievers. The 18-item ICSG was shown to have strong internal consistency, high test–retest reliability, and convergent and incremental validity and supported a two-factor model, measuring one's insecurity with God and the disruption in one's religious practice.


Introduction
Contemporary research has revealed that the death of a loved one can elicit a variety of responses in survivors.Psychologically, many bereaved individuals are able to bounce back relatively quickly after the death [1].Some grievers experience symptoms of grief-related distress (e.g., anguish, sorrow) for a year or more before they are able to incorporate the loss into their lives [2].Still other bereaved people struggle tremendously in coming to terms with the death or in making a life for themselves without their treasured loved one.This chronic condition, known as complicated grief (CG) [3], prolonged grief disorder [4], or persistent complex bereavement disorder [5], is a protracted, debilitating, sometimes life-threatening grief response.CG is characterized by a state of persistent grieving, wherein the mourner experiences profound separation distress, psychologically disturbing and intrusive thoughts of the deceased, and a sense that life is empty and meaningless [6,7].
Mounting research also suggests that for a subset of mourners who are spiritually inclined, bereavement can usher in a crisis of faith-a distinct time when their spiritual ways of experiencing and understanding life and their long-held religious beliefs are called into question.In the context of bereavement, prolonged and debilitating spiritual distress of this sort, which includes the collapse or erosion of the griever's sense of relationship to God and/or their faith community, has been termed complicated spiritual grief (CSG) [8,9] and has shown an empirically consistent association with CG [7,[10][11][12][13].
For spiritual leaders, clinicians, and researchers who seek to create, apply, and assess psycho-spiritual treatments for spiritually inclined mourners who struggle with their faith following loss, this link between CG and CSG is critical.Until recently, however, in terms of measuring levels and aspects of spiritual distress experienced by grievers, there has been a paucity of bereavement-specific instruments to do so.This meant that those serving grievers were limited to the use of generic measures of spiritual struggle.Thus, Burke, Neimeyer, Holland et al. developed, tested, and validated a new measure of spiritual distress called the Inventory of Complicated Spiritual Grief (ICSG; see Appendix) [14] to bridge this critical gap.In terms of evaluating a griever's level of spiritual distress in the context of bereavement, to our knowledge, the ICSG is the only validated instrument in the field.

The Need for a Bereavement-Specific Measure of Spiritual Distress
Historically, researchers have measured spiritual struggle by accessing negative emotions, behaviors, and attitudes that an individual experiences in relation to God and, in some cases, to his/her spiritual network of believers.Specifically, studies have been conducted that examine spiritual distress using a single item (e.g., [15,16]), others use factor analysis to derive subscales [17], and still others investigate this construct using event-specific scales (e.g., [16]).Pargament et al.'s [18] Brief RCOPE includes two subscales, with one designed to capture signs of supportive spirituality (e.g., positive religious coping (PRC) and the other to capture signs of spiritual distress (e.g., negative religious coping (NRC); see also the Spiritual Assessment Inventory (SAI) [19]; Attitudes Toward God Scale-9 (ATGS-9); [20]).Although useful, these instruments assess spiritual struggle using only a few items.Some researchers support the parsing of such subscales into specific items (e.g., [21]), finding that this informs their exploration of aspects of spiritual struggle, such as anger and disappointment with God.Now, however, the development and validation of a psychometrically sound measure designed specifically to capture signs of spiritual distress in bereavement (i.e., ICSG) can advance grief research in new ways.Specifically, a more nuanced understanding of spiritual aspects of bereavement processes is now possible with the development of a measure of distinctive aspects of spiritual struggle, such as doubt and resentment toward God, dissatisfaction with religious activities and fellowship, and substantial changes in the griever's spiritual beliefs and behaviors following the loved one's death (see also [11]).
Compared to the more generic assessment of spiritual struggle found in such scales as the SAI (e.g., There are times when I feel betrayed by God; [19]), the Brief RCOPE (e.g., Felt abandoned by God; [18]), and the ATGS-9; (e.g., Felt angry at God; [20]), the ICSG provides a more fine-grained inquiry of spiritual crisis (e.g., I don't feel very much like joining in fellowship to praise God or to glorify Him; or I sense the absence of God more than I do the presence of God).Thus, CSG can be more comprehensively evaluated using the ICSG with its wide array of candidate items bearing on spiritually imbued responses reflective of the grief associated with the loss of a loved one.Currently available scales, such as the SAI [19], the Brief RCOPE [18], and the ATGS-9; [20], all of which were validated with non-bereaved adult samples experiencing a wide assortment of life stressors, may fail to measure spiritual crisis in the specific context of bereavement.Therefore, in an effort to help grievers reestablish a loving and close relationship with God "during times of frightening vulnerability" ( [8], p. 304) and derive meaning from the deceased's life and death [22], Burke and her colleagues' [14] goal was to shed additional light on mourners' spiritually inflected struggles by testing their grief-specific scale with two diverse samples of bereaved adults.

Development
The original 28 items on the ICSG (see Appendix A) were derived from the results of several studies where data were collected from written self-reports and focus group participants, all of whom endorsed a Christian religious framework [9,11] and from ongoing collaboration with church pastors who routinely serve bereaved congregants.The original construct of CSG and interest in testing it arose from a study conducted by Shear and her colleagues [9].Pastors at a large, well-established, Protestant church requested that Shear's research team develop and test a two-session, faith-oriented treatment for bereaved parishioners.To ascertain the affects of the loss on their faith, the researchers evaluated the grief experiences of a sample of African American congregants (N = 31).With response options ranging from "faith stronger than ever" to "faith seriously shaken," 19% of participants endorsed feeling as if their faith had been negatively altered by the death.This type of "spiritual grief" ( [9], p. 7), as Shear's group referred to it, reflects a form of spiritually permeated anguish that arises when survivors protest the loss as being ostensibly untimely or unfair.Similarly, when believers, who view life events as being mediated by the hand of God, sense that the death of their cherished loved one came as a direct result of that same hand, this scenario can destabilize the griever's spiritual sense-making, as all of life's well-established assumptions are now likewise called into question.
Many researchers view grief reactions as falling on a continuum of highly resilient to severely complicated responses.For Shear and her colleagues [9], CSG occurs similarly.Grief that is expressed in spiritual terms is similar to grief that is experienced psychologically, where CSG characterizes the most problematic spiritual responses of all.

Validation
To more fully evaluate the psycho-spiritual construct of CSG, Burke, Neimeyer, Holland et al. [14] developed and validated the ICSG.First, in one sample, exploratory factor analysis (EFA) was used to test the scale's factor structure.In another sample, confirmatory factor analysis (CFA) was used.Second, associated constructs were examined to test convergent validity.Third, with scores from a general-purpose measure of spiritual struggle held constant, items that were correlated with complicated grief symptoms were used to test incremental validity.Finally, the ICSG was evaluated for test-retest reliability and internal consistency.Burke and her colleagues hypothesized that scales of complicated grief and NRC would reveal a positive association with ICSG, and a negative association with scales of meaning making and PRC.
The ICSG was tested using data from two samples [14].One, the community sample, was made up of 152 adult grievers.The second, the college student sample, was made up of 152 bereaved University of Memphis psychology undergraduates.Psychometrically, an 18-item scale with two subscales emerged-Insecurity with God and Disruption in Religious Practice.An exploratory factor analysis that was conducted using data from the community sample supported this two-factor model.This model's generalizability was evidenced through use of confirmatory factor analysis, which was conducted using the student sample data.Consistent with initial hypotheses, the ICSG performed satisfactorily in providing a stable and coherent measure of spiritual distress in bereavement, which was evident in the high test-retest reliability and internal consistency of the ICSG total scores and both subscales.
Burke and her team [14] used the scale's item content to show that Insecurity with God, which was the first seven-item factor, measured the level to which the bereaved person struggled with confusion in relation to God, questioned His protective nature, and felt angry at God during bereavement.Disruption in Religious Practice emerged as an 11-item factor that evaluated the extent to which the death interfered with the mourner's religious practices, ability to worship, and relationship with his/her spiritual community.The sum of all items equals the ICSG's total score.Subscale scores and total scores were correlated with representative scales in expected directions, indicating convergent and discriminant validity.In terms of convergent validity, for example, the following measures were statistically significantly associated with ICSG total scores in both the community and college student samples, respectively: the Inventory of Complicated Grief-Revised (ICG-R; [7]; r = 0.34, r = 0.49), the NRC subscale of the Brief RCOPE ( [18]; r = 0.43, r = 0.50), and subscales of the Religious Coping Activities Scale (RCA; [23]), including Discontent (r = 0.53, r = 0.57) and Plead (r = 0.31, r = 0.23).In relation to discriminant validity, ICSG total scores showed a statistically significant negative association in both samples, respectively, with the following measures: the PRC subscale of the Brief RCOPE (r = ´0.36,r = ´0.50),subscales of the RCA, including Spiritual Based Coping (r = ´0.49,r = ´0.63),Good Deeds (r = ´0.32,r = ´0.45),Interpersonal Religious Support (r = ´0.15n.s., r = ´0.31),and Religious Avoidance (r = ´0.27,r = ´0.42),and meaning making as assessed using the Integration of Stressful Life Experiences Scale (ISLES; [24]; r = ´0.28,r = ´0.48).Thus, on the one hand, higher ICSG total scores were related to elevated levels of complicated grief, negative religious coping, religious discontent, and religious pleading.On the other hand, higher ICSG total scores were related to lower levels of positive religious and spiritual coping, religious good deeds, interpersonal religious support, religious avoidance, and meaning made of loss.
Even after controlling for scores on the NRC subscale of the Brief RCOPE (a non-grief-specific measure of spiritual crisis), elevated levels of complicated grief were correlated with high levels of ICSG total scores in tests of incremental validity.This held true for both the college student samples (β = 0.36, p < 0.001) and the community samples (β = 0.22, p = 0.009).
Good internal consistency was found for both subscales (Insecurity with God, α = 0.89 and 0.87; Disruption in Religious Practice, α = 0.93 and 0.96) and for the 18-item ICSG as a whole (α = 0.92 and 0.95) in the community and college student samples, respectively.
Evidence of the ICSG's long-term stability was documented in the form of high test-retest correlations for both subscales (Insecurity with God, r = 0.96, p < 0.001; Disruption in Religious Practice, r = 0.95, p < 0.001) and ICSG total scores (r = 0.97, p < 0.001) through use of follow-up data (3-4 weeks after the initial evaluation) from a subset of the college-aged grievers (n = 31).

Clinical Applications
The ICSG is clinically useful in evaluating the spiritually inclined griever's faith journey during bereavement.Additionally, it can help determine specifically which religious/spiritual issues might come up for a given believer while engaged in therapy.Because both mental health professionals and their spiritually distressed clients often feel unsure about how to broach the topic of spiritual discord following a death, use of an additional tool such as the ICSG is sometimes warranted.For example, in some cases, it may be that a therapist approaches discussions of a spiritual kind with hesitation and cautiousness.In other cases, it may be that a bereaved client feels a sense of self-disappointment and shame in expressing his/her honest sentiments toward God.Whatever the scenario, introducing conversations centered on such things as the survivor's confusion about how to make spiritual sense of the death, feelings of abandonment by fellow congregants, disappointment with God, or other complicated and emotive topics, thoughts, and responses can be challenging for many mourners.
Prior to its empirical validation, Burke and her team [14] recruited spiritually inclined grieving adults from a pool of eligible participants to partake in a focus group designed to refine the ICSG's content to better reflect the experience of spiritually inclined mourners.Five grievers participated in the focus group based on their endorsement of high levels of distress in terms of CSG, assessed using quantitative scales (e.g., the NRC subscale of the Brief RCOPE [18] or the Discontent subscale of the RCA [23]), or whose narrative responses to four open-ended questions (related to their thoughts and feelings about their relationship with both God and their spiritual community following the loss and about the ways in which the loss strengthened or challenged those relationships) suggested present, or past, spiritual distress (i.e., earlier in the bereavement period).Focus group members were diverse in terms of age, race, time since loss, and cause of death and are briefly described here: Elaine, 1 a 65-year-old African American woman who lost her 24-year-old son, Bronson, to homicide 6.6 years prior; Latisha, a 36-year-old African American woman who lost her 69-year-old grandmother, Mabel, to natural, anticipated causes 9.4 months prior; Rhonda, a 23-year-old Caucasian woman who lost her 55-year-old mother, Norma, to natural, sudden causes 8.1 months prior; Caroline, a 59-year-old African American widow who lost her 55-year-old husband, Ronald, to homicide 3.5 years prior; and Suzanne, a 19-year-old Caucasian woman who lost her 68-year-old grandmother, Nell, to accidental causes 7.3 years prior.
The focus group participants were asked 15 questions derived from the results of prior narrative analyses.Members' responses were coded using directed content analysis to develop an a priori coding scheme.Completed analyses were followed up with member-checking and triangulation of the data.
1 Pseudonyms are used for focus group members, clients, and patients throughout manuscript.
Thus, conclusions drawn upon to inform the ICSG stemmed from the results of three sets of data (i.e., the quantitative measures, the open-ended questionnaire, and the focus group sessions).
The responses of focus group members and other research participants who contributed written narratives revealed an overarching story of resentment and doubt toward God, dissatisfaction with the spiritual support received, and substantial changes in their spiritual beliefs and behaviors following the death.For instance, with regard to God, one participant's narrative spoke volumes about the source of clinically significant distress that highlighted how her assumptions about life and God had been shattered [25], compromising her ability to make spiritual sense of the death.Selena, a 29-year-old Caucasian woman who was grieving the loss of her 60-year-old father who died suddenly of natural causes, exclaimed, "I was very angry at God.I didn't want to pray or read my Bible.I was confused because of how I thought God was supposed to be.I knew in my heart that I could never turn my back on God because there is nowhere else worth turning, but I felt very betrayed by him." To further illustrate Selena's sense of betrayal, we highlight below how items on the ICSG helped to identify the spiritual struggle of one severely distraught mother in her spiritual quest for meaning and purpose.Cassandra is a 34-year-old African American mother who was grieving the loss of her 2-year-old son following a tragic accident.She told us, "The first thought was 'What did I do wrong to cause my son to die?' I thought that maybe I hadn't been 'good' enough or had committed some sin that I wasn't aware of.I longed for the presence of God, to feel him near.By presence I mean a strong sense of peace."Whether Cassandra's expectations of God are valid is irrelevant.What her testimony tells us is that many believers have a well-developed perception of how God should interact with them, especially in times of dire need, and when those expectations are violated by subsequent events, in their eyes, God has failed them.
In relation to her would-be spiritual supporters, Cassandra added, "I felt that I was wronged by those in my spiritual community, because I was told to 'live right' and God would bless me.I knew that struggles would happen but not something as senseless as my baby dying.I felt a struggle between my faith and my feelings of anger, sadness, and terror.In fact, I lost confidence.At one time, I reverenced those in my spiritual community who I thought had the answers to the 'spiritual life' that one should lead.Most that I was in contact with before the loss seemed to have all the answers, but, after my son's death, they had none.But instead of saying that, they just abandoned me and my family.We were left alone with our grief.Eventually, we left that particular place of worship and found a new place."Here, Cassandra's narrative highlights how CSG is not primarily about disgruntled, disillusioned believers walking away from God.Rather, it appears to be primarily about spiritually hurting individuals who are desperately searching and seeking to make spiritual sense of their loss and are coming up short.Her experience confirms the surprising finding that a spiritual crisis does not necessarily indicate immature or weak faith [11].Rather, when facing life without a treasured attachment figure, even people with a firm faith in God can unexpectedly falter under the burden of grief.Even when grievers walk away from God and/or their faith network, it does not rule out their return to either at a later date, especially once their grief symptoms subside.
Thus, by simply asking clients to complete the ICSG between or before sessions, counselors could find the scale useful as a therapeutic conversational catalyst for healing.The therapist might suggest that the patient "Start anywhere...Which of these items that you marked are important for you today?Are there one or two that really set you off when you think about God or your church?"As the clinician invites deep probing of the client's pain in order to craft and utilize treatment techniques precisely suited for the situation, discussions can ensue in which the spiritually distressed griever can finally speak the unspeakable.Often, up until that point, the person has held back a world of hurt, disappointment, discontentment, and resentment toward God, sensing that to directly target God or a fellow believer is somehow incongruous with being a "good Christian."Thus, a troubling loss can elicit confusing and complex emotions that well up inside a spiritually inclined griever but with no clear place to direct them.Such was the case for Clarina, a 68-year old Caucasian client, who consulted a therapist (LAB) and endorsed high levels of spiritual distress on the ICSG seven years after the death of her husband following a lengthy battle with cancer.Follow-up conversations revealed a palpable reluctance to expound on any of her endorsed responses, stemming from what she referred to as the "fear-based faith" tradition in which she was raised.In fact, she was afraid to be angry with God, though she clearly was.She was timid about questioning his judgment, though everything within her screamed to do just that.Completing the ICSG, with its descriptive statements indicative of spiritual conflict, opened Clarina up spiritually, creating a willingness to explore her disgust, distrust, and disappointment with God in ways that felt safer than engaging in a verbal protest.Thus, introducing the ICSG items on paper gave Clarina an avenue with which to express her long-held pain and resentment.She subsequently took the therapist's suggestion to read a book on the same theme [26], which then became a weekly therapy topic that she initiated rather than avoided.Interestingly, similar methods also have been used successfully with mourners who are angry with God but who have long ago denounced their faith or who claim to never have espoused faith in the first place.For still other bereaved Christian clients who are open and willing, the provider can facilitate healing through a chairing experience [27][28][29], for example, where the survivor holds an imaginal conversation with God (or a fellow parishioner), allowing for a full expression of anger, anguish, and sorrow in a safe, supportive setting.

Limitations
Even though the ICSG has been tested with both African American and Caucasian samples, it remains to be seen whether the scale can be meaningfully used with bereaved individuals in other faith traditions, especially given that the items originated with Christian participants.For example, the ICSG likely would not be suitable for most non-monotheistic faith traditions (i.e., ones that are not variations of Christianity, Judaism, or Islam), especially given its focus on a personal relationship with God, church attendance, and frequent fellowship with a like-minded community of believers.For this reason, other measures should be developed to better assess unique spiritual struggles that are expressed by grievers from other traditions of faith or belief (e.g., Buddhism, Hinduism, or less theistic spiritual or secular world views) using non-Christian terms and references.

Conclusions
The ICSG is an easy-to-use, multidimensional scale of spiritual crisis during bereavement that can be used in a variety of clinical settings and with a range of research samples.Our review of this scale leads us to hope that the ICSG will be widely used by providers of psycho-spiritual care and researchers as they evaluate and treat the phenomenon of spiritual struggle as it pertains specifically to grief rather than in the form of NRC or general spirituality.Moreover, the ICSG enables clinicians to distinguish between types of spiritual struggle-in terms of one's relationship with God or with their community of spiritual practice.Going forward, as this work proceeds beyond that of Christian or Abrahamic traditions, researchers should empirically test whether loss-related spiritual struggle is experienced by spiritually inclined individuals regardless of their faith tradition or lack of one.We also foresee that having a tool to measure the construct of CSG might make a valuable contribution to both research and practice in a way that ultimately promotes better grief outcomes.For example, future research that explores possible links between CSG and post-traumatic growth, or that develops and tests therapeutic interventions designed to ameliorate spiritual distress and promote resilience and meaning making among mourners could advance the field in terms of clinical understanding and by fostering positive outcomes in bereavement.Thus, we consider the ICSG to be useful in conceptualizing, appraising, and reporting grief-specific spiritual crises in response to a wide variety of applied disciplines, whether pastoral, clinical, or empirical.

22.
I am a faithful believer, so I don't understand why God did not protect me.

23.
My focus is more on my loss than on the will of God.24.
I have lost my desire to worship.25.
I find it impossible to worship.26.
I sense the absence of God more than I do the presence of God.27.
The tragedy of my loss has made me question whether God truly exists.28.
I have concerns about my loved one's eternal welfare.

Inventory of Complicated Spiritual Grief (ICSG)
Please think about your loss of _______________, and then read each statement carefully.Choose the answer that best describes how you have been feeling during the past 2 weeks including today.Please answer these based on how you actually feel, rather than what you believe you should feel.

Mostly true
Very definitely true 1) I don't understand why God has made it so hard for me.0 1 2 3 4 2) I have withdrawn from my fellowship with other believers.0 1 2 3 4 3) I go out of my way to avoid spiritual/ religious activities (e.g., prayer, worship, Bible reading).18) I am a faithful believer, so I don't understand why God did not protect me.0 1 2 3 4 Notes: A sum of all items can be taken to compute an ICSG total score.Likewise, items 1, 4, 7, 10, 13, 16, and 18 can be summed to compute the Insecurity with God subscale, and items 2, 3, 5, 6, 8, 9, 11, 12, 14, 15, and 17 can be summed to compute the Disruption in Religious Practice subscale.
This scale is published in the public domain to encourage its use by interested clinicians and researchers.No formal permission is required for its duplication and use beyond citation of its source and authorship.

5 ) 8 ) 9 ) 11 ) 12 ) 17 )
I find that spiritual/religious activities are not very fulfilling (e.g., prayer, worship, I find it difficult to surrender my life to God.I don't feel as comforted by church fellowship as I used to.I don't feel very much like joining in fellowship to praise God or to glorify Him.The strong guiding light of my faith has grown dim and I feel lost.I sense the absence of God more than I do the presence of God.