key: cord-0960917-xpzcvqbz
authors: Smid, Geert E.
title: A framework of meaning attribution following loss
date: 2020-10-02
journal: European journal of psychotraumatology
DOI: 10.1080/20008198.2020.1776563
sha: 2bdb4d87bd8632b9de910b7a87f9463fef104a81
doc_id: 960917
cord_uid: xpzcvqbz

The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor’s life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor’s functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.

La pérdida de un ser querido hace que el mundo y el lugar del deudo sobreviviente, cambien irreversiblemente. Un aspecto clave del proceso de duelo es la integración de la pérdida en la historia de vida del sobreviviente, el cambio de identidad y una nueva orientación futura a través de la atribución de significado. La atribución de significado puede tener efectos favourables o desfavorables en el proceso de duelo y, por lo tanto, determina el grado en que una pérdida interfiere el funcionamiento del sobreviviente en duelo. Se presenta un marco de atribución de significado después de la pérdida, que comprende 17 determinantes que se dividen en cinco categorías: determinantes relacionados con el evento, culturales, sociales, individuales y relacionales. Cada determinante puede conducir a significados positivos y negativos, lo que facilita o complica el proceso de duelo. El marco de atribución de significado resalta la importancia de una red integrada para la atención de salud mental, atención espiritual y la atención al final de la vida en la prevención y el tratamiento del duelo traumático. También enfatiza el apoyo de parientes, rituales colectivos, puntos de vista culturales, acuerdos legales y otros factores sociales que pueden fomentar o impedir la adaptación a la pérdida. El marco de atribución de significado nos habla de la investigación en una variedad de temas de investigación, incluida la atención especializada para el duelo traumático, una red de atención culturalmente sensible para el duelo traumático y la mejora de la atención para la pérdida ambigua en un contexto global.

Horremus ignota. SENECA The unknown inspires us with fear and life confronts us with constant changes. Many of our thoughts, feelings and behaviours are aimed at keeping our living environment predictable and familiar. We strive to ensure the continuity of our existence and to limit the unpredictability of life to an acceptable level. To the most important sources of stability in our lives belong our lasting relationships with other people. However, the changes that life brings defy our capacity to guarantee continuity. Traumatic losses mark breaks in continuity. Events that are so shocking that our relationships, behaviours, feelings and thoughts cannot compensate. We are left with the unknown that frightens us so much. We struggle to attribute meaning to what happened, sometimes a lengthy process. I will discuss the process of attributing meaning and the factors influencing this process: how we fill in the unknown, the void of loss. I start with a quote from a grief-focused therapy (the therapist is me, and permission to use this quote was granted by the client).

Even if I had been in Syria, he would have been dead. There is nothing else. But what made me feel guilty is because I left him alone and he died. We must be beside him. That's it. That's what made me guilty. You feel that still? Yes of course, yes. Because I left him alone, and we couldn't visit him in his grave. So he is alone now. I wish if I just could visit him in the grave, but there is no way. If I could go now, I would be beside him. But this thought really … Yes, it is in my mind all the time, yes. You actually want to keep him company. Yeah, I want. Because no one from our family is in Syria. All of us are out of Syria. No one visits his grave, no one speaks with him, no one stays with him. [Silence] You hear a son talk about his deceased father and a feeling of guilt that comes with the memory of his father. An intense longing for proximity that is impossible due to war and destruction. Although he realizes that his father is dead, he misses the prescribed rituals, such as visiting the grave.

In a description of the phenomenology of grief, Fuchs (2018) notes that bereaved person experiences a fundamental ambiguity between presence and absence of the deceased. He or she lives as it were in two worlds (Fuchs, 2018) . A shared world with shared habits has been lost, and the smallest details in the remaining world can be indicative of the absence of the deceased. Two strands of time arise, which become more and more asynchronous, namely a still-going past and an alienated present. Often there is an 'as if presence' of the deceased whom the grieving person continues to feel and sometimes perceive. A gradual, transforming adjustment to the loss follows, whereby eventually the conflicting reality can be integrated again. Different forms of representation play a role in this integration, in particular through memory, symbolization, and narration (Fuchs, 2018) .

The loss of loved ones causes the world and the place of the bereaved survivor in it to change irreversibly. An identity change follows, as is sometimes apparent from the fact that the bereaved survivor's new social role is marked with a new name. A woman who loses a husband becomes a widow; a spouse who loses a wife becomes a widower; a child who loses his or her parents becomes an orphan. There is no name for a parent who loses a child, except in Chinese: shiduer, literally people whose child died. This word has negative associated meanings and originated as a result of the one-child policy in China (Zheng, Lawson, & Head, 2017) .

Meaning attribution comprises integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation (Gillies & Neimeyer, 2006; Janoff-Bulman & Pherson Frantz, 1997) . Meaning attribution reduces the fear of the unknown, one of our most fundamental fears (Carleton, 2016) . Meaning attribution after loss is therefore an adaptive process that helps people to survive as meaning attributing beings. To be able to tell the story to oneself, it is often necessary to tell the story to others. An involved, empathetic listener, as Mollica described: 'The foundation of storytelling is the capacity of human beings to empathically listen to the suffering of others, an act that is therapeutic for the storyteller and beneficial to the Iistener' (Mollica, 2006, p. 115) . As humans, we can both contribute to and receive compassion. Empathy and meaning attribution are related human capacities with an impressive evolutionary history. They form the basis of the human capacity for care provision and recovery. The knife cuts on two sides. Putting trust in these human capacities constitutes a humanistic ideal. Humanism is an ethics of trust in human nature (Renaudet, 1945) .

Death, loss and grief have meanings that influence the functioning of individuals, families and communities. Meaning attribution can determine the extent to which a grieving process disrupts the bereaved survivor's functioning (Milman et al., 2019) . While some survivors can resume their normal lives after a short time, others seem to get stuck in a process that takes years or even decades to complete.

In recent years a grief disorder has been included in formal diagnostic systems for the first time. More specifically, in the eleventh edition of the World Health Organization's (WHO) International Classification of Diseases (Killikelly & Maercker, 2017; WHO, 2018) and the fifth edition of the American Psychiatric Association's (A.P.A.) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (A.P.A., 2013). If grief reactions are severe and give rise to long-term impairments in daily functioning, a diagnosis of a grief disorder may apply. It is estimated that about 10% of the relatives develop a grief disorder after loss of a loved one due to natural causes of death (Lundorff, Holmgren, Zachariae, Farver-Vestergaard, & O'Connor, 2017) . In addition to these 10% that may benefit from specialized care such as psychotherapy, it is estimated that around 30% of surviving relatives need some form of non-specialized, organized support (Aoun et al., 2015) .

In order to be able to provide effective support, it is crucial to understand how meaning attribution takes place following bereavement and grief. How do we interpret the loss of loved ones? How do we evaluate ourselves and the world when something happens to our loved ones that we have always tried to prevent through our daily care? How do we learn to cope? First, I will discuss the circumstances that have an impact on meaning attribution to the loss of loved ones. What determines how we evaluate, interpret and attribute meaning to loss experiences? In other words, what are determinants of meaning attribution following loss of loved ones? I then consider the implications for research.

Meaning attribution involves connecting events and circumstances. The meaning that people attribute to bereavement and grief depends to a large extent on the events that led to the death of the loved one, the cultural background, social circumstances, individual factors and the relationship with the deceased loved one -both before and after the death. This categorization is arbitrary: in fact the same determinant can fall under different categories. A multiaxial model by Good and Hinton (2016) outlines different analytical perspectives on the aftermath of psychotrauma, which they call the trauma survivor's ontology (Good & Hinton, 2016) . Building on and expanding this model, I will present an overview of determinants of meaning attribution after the loss of loved ones. These determinants constitute anchoring points for the story of the loss.

We can be at peace with the death of a loved one under favourable circumstances: due to nonviolent causes, after a long and happy life. It helps us to accept when things go as they should. The risk of disordered grief is substantially increased in bereaved persons due to violent circumstances, such as an accident, disaster or violence -we also refer to this as 'non-natural causes of death' and 'traumatic loss' -compared to natural causes of death (Boelen, de Keijser, & Smid, 2015; . It is estimated that violent circumstances confer a five-fold increased risk of a grief disorder. Indeed, our recent meta-analysis yielded a stunning 49% risk of grief disorder following traumatic loss (Djelantik, Smid, Mroz, Kleber, & Boelen, 2020a) .

Grief comprises emotional pain related to the death of a loved one, feelings of yearning and longing, and preoccupation with the deceased person or the circumstances of the death (A.P.A., 2013; WHO, 2018). The emotional pain can take the form of intense sadness or pangs of grief, bitterness, anger, guilt, denial, reproach, difficulty accepting death, a feeling of having lost part of oneself, inability to experience positive feelings, and difficulty in engaging with social or other activities. The death of a loved one due to violent causes can also cause post-traumatic stress disorder (PTSD), characterized by intrusive memories, attempts to avoid them, negative thoughts and mood and increased reactivity.

Emotional responses to the loss of a loved one are not only a result of the meaning that the relationship with the loved one had -and still has -for the bereaved survivor, but in turn contribute to the meaning that is attributed to the loss. Violent emotional reactions can give rise to the fear of going mad with sadness. Lack of emotional reactions can be just as confusing, for example, if the absence is perceived as an indication that one didn't care much about the deceased.

In Western cultures, grief is connected to individual processing and acceptance. This can be different in non-Western cultures. Emotional and physical reactions following the loss of a loved one can be explained as a result of actions of the spirit of the deceased loved one. Traditional beliefs may hold the view that circumstances surrounding the death can cause the spirit of the deceased to bring distress onto the bereaved because it cannot find rest or resents leaving the land of the living. Also, dreams and hallucinations of the deceased person or other forms of encounters with the deceased person may have cultural explanations (Smid, Groen, de la Rie, Kooper, & Boelen, 2018) .

What does death mean? What does it mean for my deceased loved one? What does it mean for me when I die later? Religious and spiritual doctrines about persistence refer to the afterlife that may have spatial and temporal aspects. Sometimes only the afterlife seems to be the place where justice exists (Almond, 2016) . A solution for the injustices on this side of the grave is to even them up on the other. After death the righteous will receive their rightful reward and the wicked will receive their deserved punishment.

The idea that aspects of the condition of the deceased at the time of dying are perpetuated after death may be a source of persistent distress in traumatically bereaved individuals. Ideas about the spiritual state of the deceased in the afterlife may influence meaning attribution to dreams about or other encounters with the deceased. For example, according to a Buddhist belief system, certain dreams may be interpreted as evidence that the deceased is in a dire spiritual state, indicating the need to perform appropriate rituals (Good & Hinton, 2016; Hinton, Peou, Joshi, Nickerson, & Simon, 2013; Smid, Groen et al., 2018) . Inability to perform such rituals can give rise to feelings of guilt.

Sometimes, grief involves an all-encompassing loss of trust in the personal and impersonal world. A sense of safety and continuity is gone; one inhabits a world where the incomprehensible is possible. Reactions from one's social environment play a role: whether others share in one's grief, understand it or fail to understand it, listen or pretend to listen, offer genuine support, retain an emotional distance or withdraw altogether. The world not only seems different because the loved one has died, but because others seem different too (Ratcliffe, 2015) . Social support is of great importance for the processing of loss and trauma (Cohen & Wills, 1985; McKissock & McKissock, 1991; Ozer, Best, Lipsey, & Weiss, 2003) .

Cultural factors may influence a bereaved individual's decisions to seek help, whether or not to rely on family, religious leaders, the community, and professional care (Good & Hinton, 2016; Smid, Groen et al., 2018) . The effects of care provision and assistance may in turn affect meaning attribution following the loss.

Does the loss of the loved one also mean the end of the group to which the bereaved survivor and the deceased belonged? Many social rituals surrounding the funeral confirm the survival of the group within which the memory of the deceased is honoured. Shared cultural traditions promote social connectedness while at the same time protecting uniqueness of the individual and his or her cultural group. But sometimes the loss of a loved one also involves the loss of the group to which the bereaved survivor belonged. The term cultural bereavement (Eisenbruch, 1990 ) describes distress in refugees exposed to losses of loved ones as well as their culture. The cultural identity must then be redefined, which may be a far-reaching process. Cultural identity concerns all the norms and values that constitute an image that the individual holds of him or herself, that urges an individual to decide what is right or wrong and what kind of behaviour is appropriate or not. These individual norms and values originally were shaped by norms and values negotiated within the cultural group and local society to which the individual belonged (Groen, Richters, Laban, & Devillé, 2018) . With the loss of connection with the cultural group and a change of local society, the entire foundation of individual norms and values are gone and have to be rebuilt.

Stigma occurs when the social environment reacts negatively to a person's grief. If negative reactions are based on norms about grief, for example about the duration of grief, one may call these 'mourning veils,' (van den Bout, 1996) , because such norms conceal that mourning is different for everyone. Experienced stigma can be an obstacle to seeking help (Haugen, McCrillis, Smid, & Nijdam, 2017) . In some situations, cultural norms can prevent the loss of a loved one from being openly acknowledged, publicly mourned, or socially supported. The term disenfranchised grief denotes these situations (Doka, 2002) . Cultural norms may condemn the person of the deceased (for example, a person on the wrong side during the war), the relationship with the deceased (for example, an extra-marital relationship) or the circumstances of the death. Stigma related to the circumstances of the death has many varieties. Findings from a longitudinal comparative study of suicide survivors (Kõlves & de Leo, 2018) indicated that experienced stigma was significantly higher in the survivors after suicide compared to other relatives after sudden loss in the months after death. Following physician assisted suicide, grief reactions in the relatives may be more severe if they expect social disapproval (Wagner, Keller, Knaevelsrud, & Maercker, 2011) . Disappearances of persons due to state terror or drugrelated violence can lead to community stigmatization, which results in marginalization of those left behind on the labour market and peers ignoring their children in school (Smid, Blaauw, & Lenferink, forthcoming) .

Loss of a loved one may involve a loss of economic resources, which can lead to loss cycles with a strong and inherently negative meaning. Loss of resources combined with secondary and new stressors may in part explain the chronicity or progression of psychological symptoms after psychotrauma (Smid, Kleber, Rademaker, Van Zuiden, & Vermetten, 2013; Smid et al., 2012) . Reimbursement payments, compensation for damages, specific residence permits, and survivors' pensions are intended to compensate for the economic impact and restore safety, but the process of applying for and eventually receiving these -whether or notcan also affect meaning attribution in important ways.

The environmental context can cause the loss of loved ones and resources through natural or industrial disasters. But the environmental context may mean more. People develop relationships with their natural environment that are similar to interpersonal attachment relationships, for example with pets, livestock and the wider natural environment that people care for and that meets their needs. In many cultures, the natural environment forms a central element in spiritual experiences and beliefs. Loss of it can cause grief reactions, also called ecological grief or solastalgia in the context of the climate crisis (Cunsolo & Ellis, 2018) . Examples are grief reactions to euthanized sled dogs in Greenland, commemorations for lost glaciers in Iceland, the loss of sacred places due to oil pipelines in indigenous people's environments in the USA, and indigenous tribes' fear of extinction due to deforestation in the Amazonas.

Unnatural causes of death typically have juridical implications. Following criminal violence, the inquest, trial, and eventual verdict -or the absence of these -are likely to have a strong impact on the violently bereft. Does the loss also mean a loss of confidence in the legal system, the government or society? British data show that a slow trial or the absence of a judgement is accompanied by a slower recovery during specialized treatment of surviving relatives after murder (Soydas et al., 2020) . Armed conflict situations are often characterized by the absence of a functioning juridical system, forcing people to migrate with the associated political, administrative and economic constraints alongside loss of culture and social support.

Exposure to media representations can be stressful for relatives after traumatic loss and affect their interpretation of what happened or even their feelings towards the deceased. This applies, for example, to veterans from controversial war zones who witnessed overwhelming suffering and sometimes lost buddies themselves. But also the relatives of the MH17 air crash, in particular relatives who reported severe grief reactions, experienced the role of the media as stress-increasing, for example the repeated display of debris and sometimes violations of privacy (van der Velden, van der Meulen, Lenferink, & Yzermans, 2018) . People with PTSD and grief often spend a lot of time tracking news or related news, also on social media, and this is associated with increased symptoms.

Not only event-related, cultural, and social determinants affect meaning attribution. Grief is often experienced physically, as a shock, a blow, loss of solid ground or a sudden weakness. These physical sensations arise from the shared physical reality of the relationship with the loved one, such as between spouses, parents and children and within other lasting, caring relationships. Physical complaints such as palpitations, stiffening, feelings of weakness and exhaustion are common in grief and bereaved survivors can apply different explanatory models to them (Smid, Groen et al., 2018) , for example the idea that a part of oneself has died.

The stress associated with loss has direct physical effects, for example on stress hormones and immune mediators (Lopez et al., 2020; Smid et al., 2015b) . These effects may pose serious health risks. A study among elderly people over 60 showed that the loss of a loved one significantly increases the risk of death, especially in the first 90 days (Shah et al., 2012) . Causes of death included suicide, accidents, cancer, and heart disease. The bereaved survivor's broken heart: in another study in the elderly, a 21-fold increase was found in the incidence of a heart attack within 24 hours of hearing the death of a loved one (Mostofsky et al., 2012) compared with the preceding period.

Cultural norms define specific roles and responsibilities of women and men with regard to the deceased. Gender roles also influence the expression of emotions such as sadness and anger. However, a gender difference in the risk of serious grieving reactions does not consistently emerge from recent meta-analyses (Djelantik et al., 2020a; Heeke, Kampisiou, Niemeyer, & Knaevelsrud, 2017; Lundorff et al., 2017) . The phase of life matters: children and adolescents experience loss of a loved one differently than adults and the elderly. Relatively little research has been carried out into grief in children. Spuij et al. (2012) demonstrated that grief can be distinguished from depression and PTSD in children. An extreme situation arises for children where one of their parents kills the other, or who are bereaved by other forms of family violence. Arrangements around legal authority, placement and interaction with the perpetrator-parent are then specific circumstances that influence meaning attribution (Alisic et al., 2017) . The elderly are on the other side of the age spectrum. They are at high risk both for the loss of loved ones, and for developing a grief disorder as a result (Kersting, Brähler, Glaesmer, & Wagner, 2011; Lundorff et al., 2017; Newson, Boelen, Hek, Hofman, & Tiemeier, 2011) .

The personality is to a large extent formed by early attachment relationships with parents or guardians. The individual develops schemas, i.e. working models that are applied in relationships with important others. Insecure attachment consists of negative beliefs about the self and others, that may be apparent from problems in intimate relationships. Insecure attachment and the extent to which the bereaved survivor experiences his or her identity as mixed with that of the deceased loved one are important determinants of meaning attribution in grief Maccallum & Bryant, 2013) . If the bereaved survivor experiences the deceased as a strong part of him-or herself, grief reactions tend to be more severe (Maccallum & Bryant, 2013) . Other relevant attachment and personality aspects are ambivalence, dependence, neuroticism, intolerance of uncertainty (Boelen, 2010; Boelen, Reijntjes, & Smid, 2016) and stress sensitivity (Smid et al., 2015a) .

Extreme exposure to potentially traumatic situations can lead to stress sensitization, an increased reactivity to new stressors (Smid et al., 2013 (Smid et al., , 2012 . Likewise, traumatic loss may lead to sensitization of the attachment system, that is biologically based on neural circuits involved in learning, social pain and reward. Based on the fear of experiencing loss again, traumatic loss survivors may engage in anxious clinging attachment relationships or may be reluctant to enter into new meaningful relationships (Mikulincer, 2008) .

Prior experiences with loss may become linked with the current traumatic loss and thereby increase its negative meaning. Matching triggers, i.e. trauma and grief reminders may reactivate memories of the traumatic loss and/or the deceased . Loss, grief, and feelings of injustice that have persisted through generations may require revenge, retribution, or reparation, as the concept of historical trauma implies (Kirmayer, Gone, & Moses, 2014) .

With rituals we arrive at the determinants of meaning attribution that involve the relationship with the deceased. Rituals can be performed according to cultural traditions at the time of dying, the farewell or funeral and at specific moments of commemoration (Smid, Groen et al., 2018) . The inability to perform appropriate grief rituals is often characteristic of traumatic loss of loved ones and may contribute to a sense of guilt towards the deceased person. Lack of designated rituals can influence grief and symptoms of PTSD (Hinton et al., 2013) . Migration and acculturation may entail that cultural customs in the host country are perceived as less suitable to deal with life events such as the loss of loved ones. This is called cultural incongruity (Bhugra, 2005) and can contribute to increased distress following traumatic loss (Smid, Drogendijk, Knipscheer, Boelen, & Kleber, 2018) . In the treatment of traumatic grief, culturally congruent rituals can be integrated into psychotherapy (Smid et al., 2015a) .

Saying goodbye means facing the reality of the loss. Understanding and accepting the reality of the loss, the realization that the loved one will never come back, is a determining factor in grief processing within the cognitive model of grief (Boelen, Van den Hout, & Van den Bout, 2006) . In the case of many natural causes of death, saying goodbye can start before death. The concept of anticipatory grief is important in this context. This is understood to be the awareness of the imminent loss of a loved one and the related losses in the past, present and future (Holley & Mast, 2009; Rando, 1988) . The approaching death can be the subject of conversation. Research suggests that openness regarding the end of life during the terminal phase has a favourable influence on the grieving process (Swarte, van der Lee, van der Bom, Van den Bout, & Heintz, 2003; Wright et al., 2008) . This can be understood from the importance of saying goodbye. The finiteness of the relationship is integrated into the relationship, as it were. This is a possible explanation for the finding that relatives of patients who died of cancer had on average fewer grief symptoms if the death was due to euthanasia than following natural death (Swarte et al., 2003) .

Saying goodbye is not possible if loved ones go missing. The situation with which family members of missing persons are confronted is also referred to as Ambiguous loss. Ambiguous loss is characterized by the absence of rituals and can be accompanied by grief symptoms, PTSD, depression and conflicts among those left behind Boss, 2006; Lenferink, Eisma, de Keijser, & Boelen, 2017) .

The significance of the loss of a loved one depends on the characteristics of the relationship with the deceased. This includes centrality of the relationship -a parent who lived for his child, a partner who honoured his husband or wife (McKissock & McKissock, 1991) , kinship and care relationship. The death of a partner or own child has been found to pose a greater risk of disordered grief than the death of other loved ones (Djelantik, Smid, Kleber, & Boelen, 2017) . In a survey of migrants and refugees from Togo in Europe, eldest siblings who lost a parent were at increased risk of disordered grief (Kokou-Kpolou, Mbassa Menick, Moukouta, Baugnet, & Kpelly, 2017) . Eldest siblings often experienced inability to meet the expectations of the deceased and the social obligations of children towards their deceased parents as prescribed by their ethnic group (Kokou-Kpolou et al., 2017) . The cause of death can influence how the bereaved survivor experiences the relationship with the loved one. Following suicide, a feeling of rejection may predominate for a longer period (Kõlves & de Leo, 2018) .

The death of a loved one evokes feelings of guilt in many bereaved survivors. There is an inherent injustice in the fact that a loved one, or sometimes several loved ones, has or have been denied the opportunity to live on unlike the survivor, who may feel survivor guilt (Hull, Alexander, & Klein, 2002) . If a care relationship existed with the loved one -for example, parents of a child -the death can be experienced as failure of caregiving (Shear et al., 2007) . Feelings of guilt give the surviving relatives the opportunity to constantly consider scenarios in which the loved one would not have died. If only I had done this and not that, it would not have happened. With that, feelings of guilt distract from the reality of the loss of the loved one. The more the surviving relative experiences the loss as unacceptable, the stronger he may need to recall these alternative scenarios time and again. A feeling that everything could have been prevented can also give an illusion of control. Increased sense of control and decreased reality of the loss can provide a short-term psychological benefit, even if the price is an overwhelming sense of guilt. In suicide survivors, the perception that somehow he or she has directly caused the death is common. In a group of suicide survivors followed up 6 months to 2 years after the loss (Kõlves & de Leo, 2018) , both feelings of responsibility for the suicide and severity of grief were high, compared to survivors after other sudden losses. Figure 1 depicts the framework of meaning attribution.

The 17 determinants of meaning attribution are mutually related and together they form a framework. Within this framework, the bereaved survivor attributes meaning to the loss. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process, which in turn determines the extent to which a loss disrupts the bereaved survivor's functioning.

This theoretical meaning attribution framework shows similarities and differences with other theoretical frameworks of complicated bereavement and traumatic grief. The aforementioned multiaxial model of the trauma survivor's ontology (Good & Hinton, 2016) provided the starting point for the current framework. The multiaxial model comprises the first 11 determinants of meaning attribution included in the current framework, with slightly modified terminology. The current framework of meaning attribution contains an additional 6 elements -two determinants from the 'individual' category (attachment and personality, and personal and intergenerational history), and all four determinants comprising the 'relational (with deceased)' category. In addition, the current framework differs from the multiaxial model in that it contains 5 categories overarching the 17 model components.

Multidimensional grief theory (Kaplow, Layne, Saltzman, Cozza, & Pynoos, 2013) was developed in the context of the trauma and grief component therapy for adolescents and is based on a developmentally informed, multidimensional conception of grief. It distinguishes separation distress, existential/identityrelated distress, and distress over the circumstances of the death. Causal precursors of these three forms of distress include etiologic risk factors, circumstances of the death, and mediators and moderators, that include both individual factors (e.g., developmental stage, coping strategies) and socioenvironmental factors (e.g., parent-child communication, culture). Multidimensional grief theory includes some, but not all of the elements of the current framework and differs from this framework because of its developmental focus. Indeed, in children and adolescents, social determinants of meaning attribution may be largely mediated by parents, caretakers, and teachers.

The critical feminist ecological model (Rodgers & DuBois, 2018) describes how different systems within which individuals are embedded influence their grief reactions. These systems are conceptualized as increasingly distal, concentric levels of influence that are rooted within a certain historical context. The first level, or microsystem, includes the interpersonal environment, such as family, friends, etc. The second level, or exosystem, includes the local community as well as public policy. The third level, or macrosystem, includes the economic and cultural context, and sociocultural agents such as the media. Sociodemographic variables such as gender and ethnicity intersect with these systems and contribute to shaping grief reactions. Although the critical feminist model includes some of the determinants of meaning attribution, it does not include all, and it does not specify the relationship with the deceased as a separate category of determinants of meaning attribution.

The framework of meaning attribution differs from the other models because it juxtaposes determinants of meaning attribution without implying hierarchical relations between the different determinants. Thus, it aids researchers and clinicians in obtaining an overview of the different aspects that positively and negatively influence meaning attribution and thereby adjustment following loss.

Research into meaning attribution following loss is characterized by interdisciplinarity, methodological pluralism, and explicit orientation within the sociocultural context. The framework of meaning attribution may inform several research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and ambiguous loss in a global context.

Traumatic grief occurs when bereaved survivors develop a grief disorder following the death of a loved one. If the loved one died due to violent circumstances, bereaved survivors are at increased risk, not only of developing a grief disorder but also of (symptoms of) posttraumatic stress disorder and depression (Djelantik, Robinaugh, Kleber, Smid, & Boelen, 2020; Lenferink, Nickerson, de Keijser, Smid, & Boelen, 2019) . Meaning attribution constitutes a key element in the development of these disorders as well as in recovery. Research into traumatic grief focuses on the effects of specialist care for traumatically bereaved individuals, including cognitive behavioural therapy, EMDR (Lenferink, de Keijser, Smid, & Boelen, 2020) , brief eclectic psychotherapy (Smid et al., 2015a) within an outpatient and day clinic treatment setting (de Heus et al., 2017; Djelantik et al., 2020b) , and narrative exposure therapy. Meaning attribution may be impacted by additional stressors during treatment Djelantik et al., 2020b) . Meaning attribution and the use of rituals in grief therapy constitute another focus of attention.

People who are bereaved following suicide or euthanasia due to mental illness may face culturally dependent social disapproval that may negatively influence meaning attribution . Studies are therefore necessary to optimize the care for relatives and bereaved survivors (de Keijser, Snijdewind, Casteelen, & Smid, 2020; Smid & Casteelen, 2018) . Qualitative interviews combined with quantitative measures may be used to map how life partners of people with mental illness who died due to suicide or euthanasia experienced the period of illness and death of their partner.

The framework points to the need for an integrated traumatic grief care network, consisting of mental health care and care providers in general, including chaplains, spiritual care providers, and those providing palliative and end-of-life care, tailored to the needs of the bereaved survivors (Boelen, Olff, & Smid, 2019) . Grief is characterized by a search for meaning in which the culturally sensitive dialogue with a trusted other plays an important role. An integrated network of prsurvivorsafter other suddenofessionals that also involves also spiritual care-takers can help increase social support for the bereaved and where necessary refer to specialist treatment. Care providers can map the cultural ways of dealing with loss and grief with the help of the cultural assessment of bereavement and grief, that is proposed as a supplementary module to the DSM-5 Cultural Formulation Interview (Smid, Groen et al., 2018) . With the use of additional knowledge about cultural ways of dealing with loss, the clinician can better understand the meaning attribution of the patient and adapt elements of the treatment approach, such as rituals, where needed. Validation of the cultural evaluation includes research into clinical feasibility, applicability and utility (Lewis-Fernández et al., 2017).

For those left behind after disappearance of loved ones, ambiguous loss ensues. The uncertainty of the situation makes meaning attribution particularly difficult. Moreover, ambiguous loss often occurs in the context of complex sociopolitical situations, which may enhance the risk of stigmatization. Special attention to ambiguous loss is needed in the context of humanitarian crisis situations. Missing loved ones is a universal theme there and many care providers do not know how to deal with this (Smid, Blaauw & Lenferink, forthcoming) . In Western societies, an important type of ambiguous loss exists for those left behind after radicalization of loved ones: the radicalized family member is still there, but is no longer the same as before, or left with an unknown destination. Those left behind may experience conflicting emotions towards their loved ones and the society that 'made him/ her radicalize'. Information about the well-being of those who are left behind, their care needs and their possibilities to influence vulnerability factors for radicalization can be of great value for governments, care providers and other partners to support those who are left behind on the one hand, and to work with them on developing ways to prevent future cases of radicalization.

To sum up, a framework of meaning attribution following loss consists of 17 determinants of meaning attribution that fall into five categories: event-related, cultural, social, individual and relational determinants. They have favourable or unfavourable effects on the grieving process. In the unfavourable case, they contribute to long-term, debilitating grief symptoms in the bereaved, also called traumatic grief. The framework of meaning attribution highlights the importance of mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. But not only that. It also shows how the support from relatives, collective rituals, cultural views, legal settlements, compensation and other circumstances that are shaped by us as a society may play a decisive role. We should take this into account when we collectively shape our social, societal, and care networks. Thus, the framework of meaning attribution following loss supports a plea for humanization of our society.

This paper is based on the inaugural lecture delivered in celebration of the endowed chair Psychotrauma, loss and grief following disasters and violence at the University of Humanistic Studies, Utrecht, the Netherlands on 2 October 2020. Delivery of this inaugural lecture was originally planned on 20 March 2020, but due to the Covid-19 pandemic, it had to be postponed. Onno Bouwmeester, Ph.D., Rolf Kleber, Ph.D., and Heleen Smid, M.D., provided helpful feedback on an earlier version of this paper.

No potential conflict of interest was reported by the author.

http://orcid.org/0000-0002-9616-5234

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