What’s Time Got to Do With It?: A Time-Informed Approach to Longitudinal Research With Trauma Affected and Bereaved Populations

Traditional Approaches to Trauma-Informed Research

The traditional approach to studying the process of coping with loss and trauma is rooted in foundational theories of interpersonal development, stress and adversity, and emotional regulation or cognitive processing. In their 1999 article, Bonanno and Kaltman outline several theoretical approaches to understanding bereavement within these foundational theories. For example: (1) the cognitive stress perspective^–highlights the important role of cognitive appraisals in the process of coping with grief; (2) attachment perspective^–suggests that the continued attachment or relationship with the deceased is influential in determining bereavement outcomes; and (3) the trauma perspective^–emphasizes the role of meaning making in adaptation following traumatic loss (see also Gillies & Neimeyer, 2006; Stroebe, 2001).

While the experience of grief and mourning can be understood through the lenses of borrowed theories or models, few models are intentionally designed to solely explain the process bereavement. One such model is the grief works hypothesis. That is, the notion that survivors of loss must engage in a cognitive process with the goal of detaching from their relationship with the deceased. This is accomplished by recognizing the loss, reviewing the events leading up to and during the loss, and processing memories of the deceased (Stroebe & Stroebe, 1991; Stroebe, 1993; Stroebe & Schut, 2010). While the grief work hypothesis is largely not supported by the empirical literature (Bonanno & Kaltman, 1999), and even firmly criticized by bereavement scholars (see Stroebe & Stroebe, 1991; Stroebe & Schut, 2010; Wortman & Cohen Silver, 1989) it is the starting point for much of the current theoretical work in the bereavement field.

In response to criticism of the grief work hypothesis, several bereavement scholars have proposed alternative paradigms. For example, Rubin and colleagues (1981, 1999, 2017) propose the two-track model of bereavement, broadly, demonstrates the interconnection between the degree of functioning at the biopsychosocial level (outcome) and evolving the relationship between survivor and decedent (attachment). Similarly, Stroebe and Schut (1999) challenge the grief work hypothesis via the dual process model of coping with bereavement. Their model synthesizes the elements of other theories that apply to the context of bereavement (Fiore, 2021) and proposes two components: a loss orientation and a restoration orientation. The unique feature of the dual process model is the notion of oscillation^–that is the movement between a loss and restoration orientation (Stroebe & Schut, 1999). The appropriate employment of oscillation is theorized to be linked with healthy adaptation over time^–suggesting that the needs of bereaved individual and their mode of coping changes over time.

Despite the evolution of bereavement theory and the recognition that trauma adaptation and bereavement evolve over time (Bonanno et al., 2015; Janoff-Bulman, 2004; Stroebe & Schut, 1999; Tedeschi & Calhoun, 2004; Wortmann & Park, 2008; Zoellner & Maercker, 2006); the majority of approaches to understanding the experience of loss do not overtly account for time in their model^–and far fewer account for a subjective appraisal of time. Tracking the growing acceptance of time in the process of coping with loss can be accomplished by examining the shifts in perspective from stage models (e.g. Kubler-Ross, 1969) to longitudinal models. More recently, longitudinal model have focused on “trajectories” of adaptation, that is, archetypal pathways that encompass ways in which trauma survivors may progress through the process of coping (e.g. Bonanno, 2004). These longitudinal perspectives have advanced the field of grief and trauma to explicitly model time as a factor in adaptation and are further complimented by non-sequential, or cyclical, models of grief and trauma (Saltzma, 2019).

Cyclical models of grief and trauma incorporate two key concepts: (a) adaptation as a process without a discrete endpoint and (b) the experience of “reminders” of the loss while processing grief (Worthington, 1994). Reminders often trigger the resurgence of grief and cause the individual to revisit previously experienced phases of mourning (Jordan, 2003; Worthington, 1994).

Cyclical models are therefore closely associated with the notion of anniversary reactions because both assume that temporal triggers can re-initiate the process of coping. Anniversary reactions are thought to be largely unconscious processes in response to traumatic events and are characterized by the experience of psychological and/or physiological symptoms in response to significant dates (Azarian et al., 1999; Morgan et al., 1998; Porcelli et al., 2012). This phenomenon has been associated with higher levels of PTSD (Morgan et al., 1998), sleep disturbances (Nemeth et al., 2012), and various other psychological issues including depression, worry, and irritability (Morgan et al., 1998; Nemeth et al., 2012).

The notion of anniversary reactions implies an imbalance in the experience of time throughout the process of coping. That is, that some moments of time are more meaningful and are imbued with significant emotions more than others (Saltzma, 2019). This concept of meaningful time assumes that linear trajectories of adaptation are insufficient to model the complexity of the role of time in the process of coping with trauma and loss. In response to this gap, a new framework suggests a time-informed model, in which time is meaningful, uneven, and weighted by the individual’s subjective experience (Saltzma, 2019).

Meaningful Time Approach

The meaningful time approach recognizes two versions of time: (1) chronological time, which is linear and evenly weighted; and (2) subjective time, which is influenced by the attributions the individual makes about the given moment, and the passage of time more generally. Subjective time is neither linear nor evenly weighted, but rather it is shaped by context and culture (Saltzma, 2019). In this approach we can think of loss and trauma as external events that shift the ways in which we experience time in our lives. More specifically, this approach proposes a family of temporal triggers known as “Markers in Time” (Saltzma, 2019). These temporal triggers are thought to be important moments in time that are closely associated with the loss or trauma (e.g. date of event, birthday, anniversary etc.). Markers are described as repetitive (i.e. they occur every year), inevitable or unavoidable, and saturated with intense emotion (Saltzma, 2019). This approach further hypothesized that there is a distinct pattern to markers that emerges each year that involves three phases: (1) an anticipator phase (lead up to the marker); (2) the marker itself; and (3) a recovery phase (following the marker). Lastly, this approach proposes that because time is experienced differently around these markers, we must assume that the process of coping and the experience of adaptation is similarly different.

While we have made theoretical advancements regarding how we conceptualize time as a factor in the process of coping with trauma and loss; our methodological resources and approaches have not caught up. To that end, traditional longitudinal models do not account for the subjective attribution about time. More specifically, data collection does not account for the possibility of anniversary reactions or the unique experience of time that each participant is living within. This paper proposes a time-informed methodological approach that accounts for markers in time by centering participants data collection around a marker. We present this approach and provide a case example of a study that uses this technique to gather data in meaningful time.

Recruitment, Screening, and Consent

In total, 51 participants were recruited into the study. Three participants withdrew from the study due to challenges using the technology. Participants were recruited from a community sample of adults living in the United States. All recruitment and screening took place via phone or email. Participants were eligible to take part in the study if they were 18 years of age or older, had lost a close loved one (e.g. parent, spouse, sibling, child), were comfortable answering questions in English, and had a smart phone compatible with the wearable device. Eligible participants were provided with a welcome letter detailing the aim and tasks associated with the study. If participants agreed to participate and met all eligibility criteria, they were instructed to download the study application referred to as the mEMA application (hosted by Ilumivu, 2009). Once the mEMA application was installed on the participant’s phone, participants were registered with an account at which time they received a participant code and ID number. This code was used to sync the data entered by the participant from their phone with the Ilumivu platform (2009). A member of the research team provided the participant with their participant code and ID number and instructed participants how to enter into the application and sync the application with the Ilumivu (2009) system. This process allowed the researcher to make the online consent form available for the participant to view on the mEMA application installed on their phone. The research team member then reviewed the consent form with the participants and the participant had the opportunity to ask questions prior to consenting. Once the consent form registered with the PI, additional questionnaires were released.

Baseline Questionnaire

Baseline questionnaires were made available through the mEMA application. These questionnaires consisted of basic demographic information, including (1) age, (2) sex at birth; (3) gender identification; (4) racial/ethnic background; (5) socioeconomic status; (6) marital status; (7) educational attainment; (8) health related questions; and (9) items related to the loss of a loved one (e.g. sudden and/or violent death), in addition to the following standardizes scales: (1) The Zimbardo Time Perspective Inventory (Zimbardo & Boyd, 1999); (2) The Posttraumatic Stress Disorder Checklist standard format (PCL 5-S; Weathers et al., 2013); (3) The Cognitive Emotion Regulation Questionnaire (Garnefski & Kraaij, 2006); and (4) The Posttraumatic Growth Inventory (Tedeschi & Calhoun, 1996). The Prolonged Grief Disorder Questionnaire (PG-13: Prigerson et al., 2009) scale was also included and used to assess grief at baseline and again during the second phase of data collection. Additionally, the PI identified the target anniversary date with the participant. This date was used to set a window for the second phase of data collection using the mEMA application and wearable device.

Phase Two Target Window Data Collection

The second phase of data collection was centered around the anniversary date chosen by the participant during baseline data collection. In total, this phase of data collection consisted of 22 days: 14 days prior to the anniversary (7-day baseline), the anniversary date itself, and 7 days following the anniversary date. One week prior to the start of the data collection window the mEMA application sent a notification to the study participants to remind them that their data collection period was approaching. This message was repeated the night before data collection was scheduled to begin. During this 22-day window, the mEMA application allowed the PI to message the participants’ smartphone each day. This message reminded participants to complete the PG-13 questionnaire for that day. Respondents were able to answer the questions directly through the mEMA application on their smartphone. This application was synced with their smartwatch using Bluetooth to collect data from their wearable device. The smart watch collected the activity level and heart rate of participants during this period. At the end of the data collection window (on the 23rd day), participants received a thank you message via the mEMA application letting them know that they have completed the study and that no additional data from the EMA or wearable device will be recorded by the research team.