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[The Two-Track Model of Bereavement (TTMB)]

The loss of a loved one is considered to be one of the hardest and most painful experiences to the people that were closest and shared his or her life, and in many cases it demands change and adjustment to a new reality in all paths of life. The Two-Track Model of Bereavement is a framework for thinking about and responding to loss and bereavement. The model organizes and describes the processing of response to loss as involving two distinct domains and their interrelationship which are represented as tracks. The first track considers the influence of loss upon the bereaved’s general biopsychosocial functioning, while the second addresses the shifting personal and psychological connection with the deceased. This model was developed by the American-Israeli clinical psychologist Professor Simon Shimshon Rubin, in order to provide a theoretical framework to aid therapists, researchers and the general public in understanding the response to loss and the processes of adjusting to it across the life cycle[1].

The Two-Track Model of Bereavement helps deepen the understanding around the meaning of the loss and its effect over one’s life. It allows to define, in relevant terms, successful grieving as well as potential difficulties encountered in response to bereavement. In particular, Rubin has sought to clarify the significance of the second track which is often neglected due to it being of a more private nature and not easily assessed. In addition to the ongoing relationship or “continuing bond” with the deceased, this track includes attention to the processing of the “death story” and how it is assimilated. Both tracks have lifelong relevance to people who have lost someone who held significant importance for them.

The Model’s Elements

The Two-Track Model of Bereavement emphasizes the ongoing interpersonal connection to the deceased, alongside a perspective which focuses on the biopsychosocial responses to the stresses involved in loss. The model frames the reaction to loss and the process of adaptation to bereavement via two multi-dimensional tracks. The first track focuses on the impact on functioning, while the second track focuses on the inner and covert ongoing emotional attachment and relationship to the deceased and the processing of the “death story”[1].

Track I: Bio-psycho-social Functioning

The first Track in the paradigm addresses how the loss of a loved one can impact the physical, behavioral, cognitive, emotional and social experience of the bereaved. These can be manifest on a number of parameters including:

●     Mood changes including: cognitions and emotions of sadness, depression, helplessness;

●     Symptomatic changes in health variables such as appetite, sleep, sexuality, etc.;

●     Reactions of anxiety and unrest;

●     Stress and trauma responses;

●     Changes in patterns of family relationships;

●     Involvement and investment in work and study;

●     Changes in general interpersonal relationships (eg. friends, neighbors and colleagues);

●     Self-worth and self-esteem;

●     General involvement in various life areas;

●     Sense of meaning in life;

Track II: Ongoing Relationship to the Deceased and the Processing of the “Death Story”

The second track sees the event of loss as a major threat to the attachment system bound up with the deceased. The bereaved must process and accept the fact of death and begin to reorganize his or her relationship with the deceased involving psychological, cognitive and emotional elements. The death of a person of emotional significance interrupts the possibility of connection in the real world, but leaves space for continuing the connection through memory and consciousness. Thus Track 2 focuses on the emotional bond with the deceased, in the past and present, and the degree and quality of investment and connection present. Included here is also the processing of the “death story” and the ability to embed it into the personal narrative. Under a variety of traumatic circumstances, the experience of the loss or death may disrupt and interfere with the ability to connect to the relationship with the deceased. In this category are deaths that occur with an especially violent or traumatic component, such as suicide or murder. When the bereaved focuses exclusively on the death circumstances or when he or she effectively avoids all thoughts of the deceased because of the death circumstances, the mourning associated with Track II cannot proceed adequately.

This track includes a number of parameters including:

●     The extent of yearning and longing to renew the connection with the deceased

●     Images, memories and experiences with the deceased;

●     The level of emotional involvement and proximity to the deceased;

●     Over-engagement or avoidance of the fact of the loss, of the relationship with the deceased, or of both together;

●     The intensity and frequency of the positive memories and feelings towards the deceased which includes the degree of idealization;

●     The intensity and frequency of negative memories that are linked to thoughts about the death and the relationship with the deceased in both the past and present;

●     The presence of conflict relating to the deceased, the relationship with him or her, the  loss in any and all combinations;

●     The degree to which each of these responses are present: a) elements reflecting shock and frozen emotion; b) features of searching and a focus upon reminders of the deceased; c) depressed feelings and/or disorganization in the narratives of the relationship and or the death story; and d) the degree to which acceptance of the loss, the relationship, and of one’s new life situation are manifest.

●     Experiencing lowered self-esteem related to the loss and/or the relationship;

●     Progress towards commemoration and evolution in the relationship with the deceased and the experience of the loss.

The Development of the Model

The Two-Track Model of Bereavement was developed during the course of Rubin’s doctoral research at Boston University. Then based in Chicago, Rubin studied bereaved mothers who had lost infants to Sudden Infant Death (SIDS)[2]. His initial goal had been to compare and contrast bereaved mothers an average of 6 months following loss with those bereaved more than 4 years. A control group of non-bereaved mothers also participated. In accord with the then accepted theoretical and clinical perspective, it was assumed that the non-recently bereaved would have completed their grief and mourning, the extent to which the experience would change the bereaved mothers’ perceptions of their own vulnerability to life events was an open question. Contrary to expectations, however, the grief and mourning for both loss groups were intense and overwhelming. This presented a problem as it did not fit with current theory in the bereavement field.

Working in the 1970s, Rubin came to realize that many of the articles and books in the professional literature on loss and bereavement could be classified as belonging to one of two broad worldviews that had minimal interchange between them. The first worldview classified death as a variation within the field of coping with crisis and trauma. It effectively minimized the significance of the interpersonal aspects of the relationship between the deceased and the bereaved. The second worldview focused on the importance of the preloss relationship with the deceased and how grief and mourning were fundamentally tied to the grief over the interpersonal relationship between the deceased and the bereaved and the process of emotionally separating from the deceased.

Rubin had two challenges to address in order to construct the framework which would allow him to explain the results of his research with the highly grieving bereaved mothers. He met the first challenge by combining both the coping and the relationship worldviews into a single bifocal approach. In this way he set up a two-track ethos that defines a comprehensive model of the process of coping with loss. This combination built a twin pathway taking into account two domains: a) the biopsychosocial aspects of the response to loss occurring over time which he called the Track I axis; and b) the nature of the attachment to the deceased and its characteristics which he called the Track II axis[3]. He met the second challenge by demonstrating that the newly bereaved mothers differed from the non-recently bereaved mothers on Track I aspects of biopsychosocial functioning while on Track II’s ongoing relationship to the deceased, indeed both groups were highly involved in grief and mourning the deceased.

Rubin’s research and the subsequent theoretical, clinical and research publications were amongst the pioneering efforts that came to redefine the field of grief and bereavement. By championing the importance of distinguishing between biopsychosocial functioning and symptomatic responses to loss from the emotional bond to the deceased, Rubin’s work allowed for considering response to interpersonal loss in new ways. Loss could be seen as a potentially life-long process with the reworking of the relationship to the deceased reworked to the individual’s own evolution across the life span. The important finding that continued attachment and emotional connection to the deceased was normative for his sample of bereaved mothers, ultimately became part of the literature that contributed to the Continuing Bonds revolution. Continuing Bonds theory successfully reframed the notion of what adaptive responses to loss involves, and rejected the idea that emotional disconnection and detachment from the valued loved one were central to adaptive grief and mourning.

Rubin continues to develop the Two-Track Model of Bereavement and it’s theoretical, clinical and research aspects across a variety of bereavements, losses, and kinship relationships across the life cycle. He cites his collaboration and partnership with Dr. Ruth Malkinson and Professor Eliezer Witztum over the years as being particularly valuable to his continued growth and development in the field[4][5][6].

Research

The development of the model led Rubin and his colleagues and students in the International Center for the Research of Loss, Bereavement and Human Resilience in the University of Haifa[7] to research the experience of loss across a variety of situations. Among the research projects and publications associated with this research program are: bereavement among parents who have lost a son in war[8][9]; death of a child as a result of a car accident or suicide and its influences on parents over time[10]; bereavement among widows and partners of soldiers[11]; children's reactions to the death of a parent[12]; cultural and religious influences on the loss process for Christan, Muslim[13] and Jewish[14] communities; losses stemming from parental divorce[15][16]; etc. A major focus of ongoing research at this time is looking at the impact of cognitive decline and death upon the caring spouse. The theoretical and clinical background for this study was recently published by Rubin, Manevich, and Doron[18].

In 2009, Rubin and his colleagues published their questionnaire for assessing response to loss from the perspective of The Two-Track Model of Bereavement. The Two-Track Bereavement Questionnaire [TTBQ-70])[19]. This questionnaire includes 70 items and it was developed and validated among Hebrew, English, Arabic and Turkish speakers. Content analysis identified five factors, which make up the questionnaire: Relational active bereavement, close and positive relationships to the deceased, conflictual aspects of the relationship, general biopsychosocial functioning and traumatic perspective of the loss. The first three factors reflected Track 2 and the relationship with the deceased while the last two factors were associated with the overall biopsychosocial functioning Track 1. In 2013, a shorter version of the questionnaire was developed (TTBQ-CG31) and has been used to assess complications of bereavement and grief[20]. Over the years, additional adaptations of the questionnaire were developed. A Two-Track Control Questionnaire (TTCQ-54) allows for comparisons bereaved and non-bereaved samples. The Two-Track Divorce Questionnaire has been used to assess children and spouses responding to the impact of divorce on functioning and relationships of relevance (TTDQ). These questionnaires are available in one or more of the following languages: Hebrew, English and Arabic.

Further Reading Books

●     Malkinson, R., Rubin, S. S. and Witztum, E. (Eds.) (1993). Loss and Bereavement in Jewish Society in Israel. Joint Publisher: Canah/Ministry of Defense. (Hebrew). (294 pages).

●      Witztum,  E. (1999). Bereavement and the spirit. Ministry of Security Publications. Hebrew.

●     Malkinson, R., Rubin, S.S. and Witztum, E. (Eds.) (2000), Traumatic and Nontraumatic Loss and Bereavement: Clinical Theory and Practice. Madison, CT: Psychosocial Press/International Universities Press.

●     Malkinson, R. (2007). Cognitive Grief Therapy: Constructing a Rational Meaning to Life Following Loss 1st Edition. New York: Norton,

●     Rubin, S. S, Malkinson, R., Witztum, E. (2012) Working with the Bereaved: Multiple Lenses on Loss and Mourning (The Series in Death, Dying, and Bereavement). Taylor & Francis Group. (266 pages).

●      Rubin, S.S. Malkinson, R. and Witztum, E. (2016) The Many Faces of Loss and Bereavement: Theory and Therapy. University of Haifa Press with Pardes Publishing. (Hebrew).

●

Select articles

●     Rubin, S. (1981). A two--track model of bereavement: Theory and research. American Journal of Orthopsychiatry, 51(1), pp. 101-109.

●     Rubin, S. S. (1992). Adult child loss and the Two-track Model of Bereavement. Omega, 24(3), pp. 183-202.

●     Rubin, S. S. (1995). On life after the death of a son in war: Theory and research with the Two-track Model of Bereavement. Psychology: Israel Journal, 5(1), pp. 70-84. (Hebrew).

●     Rubin, S. S. (1996). The wounded family: Bereaved parents and the impact of adult child loss. In Klass, D., Silverman, P. & Nickman, S. (Eds.) Continuing Bonds: Understanding the Resolution of Grief. Taylor and Francis, pp. 217-232.

●     Rubin, S. S., (1999), The Two-Track Model of Bereavement: Overview, retrospect and prospect. Death Studies, 23(8), pp. 681-714.

●     Rubin, S. S., Malkinson, R. & Witztum, E. (2003). Trauma and Bereavement: Conceptual and Clinical issues Revolving around Relationships. Death Studies, 27, pp. 667-690.

●     Rubin, S.S., Malkinson, E., & Witztum, E. (2018). The Two-Track Model of Bereavement and Continuing Bonds. In D. Klass and E. Steffen (Eds). Continuing Bonds, 2nd edition. New York: Routledge.

Culture, Religion and The Two-Track Model of Bereavement

●     Rubin, S. S. & Schechter, N. (1997). Exploring the social construction of bereavement: Perceptions of adjustment and recovery for bereaved men. American Journal of Orthopsychiatry, 67(2), pp. 279-289.

●     Rubin, S. S. & Yasien-Esmael, H. (2004). Loss and bereavement among Israel's Muslims: Acceptance of God's will, grief, and the relationship to the deceased. Omega, 49(2), pp. 149-162.

●     Yasien-Esmael, H. & Rubin, S. S. (2005). The meaning structures of Muslim bereavements in Israel: Religious traditions, mourning practices, and human experiences. Death Studies, 29 (6), pp. 495-518.

●     Rubin, S.S. (2014). Loss and bereavement in the Jewish tradition. Omega, 70 (1), pp. 79-98

●     Bar-Nadav, O. & Rubin, S.S. (2016) Love and bereavement: Life functioning and relationship to partner and spouse in bereaved and non-bereaved young women. Omega: Journal of Death and Dying, 74 (1), pp. 62-79.

Trauma and Two-Track Model of Bereavement

●     Malkinson, R., Rubin, S. S. & Witztum, E. (2005). Terror, Trauma, and Bereavement: Implications for Theory and Therapy. In Y. Danieli, D. Brom & J. Stills (Eds.). The Trauma of Terrorism: Sharing Knowledge and Shared Care, An International Handbook. Haworth Press.

●     Malkinson, R., Rubin, S.S. and Witztum, E. (Eds.) (2000), Traumatic and Nontraumatic Loss and Bereavement: Clinical Theory and Practice. Madison, CT: Psychosocial Press/International Universities Press.

●     Rubin, S.S., Malkinson, R. & Witztum, E. (2007). Trauma and bereavement: Diagnostic and therapeutic considerations. Sichot/Dialogues: Israel Journal of Psychotherapy, 22(1), pp. 1-7. (Hebrew)

●     Witztum, E., Malkinson, R. & Rubin, S.S. (2019). Traumatic loss: Therapeutic intervention following traumatic death of a loved one. In Y. Lahav & Z. Solomon(Eds.)_ .From Reliving to Remembering, Resling Press. (Hebrew).

Two-Track Model Questionnaires

●     Rubin, S.S., Bar Nadav, O., Malkinson, R., Koren, D., Gofer-Shnarch, M. & Michaeli, E. (2009). The Two-Track Model of Bereavement Questionnaire (TTBQ): Development and findings of a relational measure. Death Studies, 33, pp. 305-333.

●     Rubin, S.S. & Bar-Nadav, O. (2016). The Two-Track Bereavement Questionnaire for Complicated Grief (TTBQ-CG31). In R. Neimeyer (Ed) Techniques of Grief Therapy, vol. 2. New York: Routledge, pp 87-98.

Reference

●     Rubin, S.S. & Prigerson, H.G. (2008). Bereavement. In the Encyclopedia of Psychological Trauma. New York: Wiley.

●     Silverman, P. R. & Rubin, S. S. (2015). Bereavement/grief interventions. In R.L. Cautin & S.O. Lillenfeld (eds.). The Encyclopedia of Clinical Psychology. New York: Wiley-Blackwell, pp 374-380.

See Also

●     Professor Simon Shimshon Rubin’s webpage at the University of Haifa

●     The International Center of Loss, Bereavement and Human Resilience in University of Haifa website

[1] Rubin, S.S., Malkinson, R., Witztum, E., (2012) Working with the Bereaved: Multiple Lenses on Loss and Mourning. New York: Routledge. OR PERHAPS  Working with the Bereaved: Multiple Lenses on Loss and Mourning (The Series in Death, Dying, and Bereavement), Taylor & Francis Group, 2012 (266 pages)

[2] Rubin, S., A two-track model of bereavement: Theory and application in research, American Journal of Orthopsychiatry 51(1), 1981. P. 101-109

[3] Rubin, S. S., The Two-Track Model of Bereavement: Overview, retrospect, and prospect, Death Studies 23(8), 1999, p. 681-714.

[4] Malkinson, R., Rubin, S. S. and Witztum, E. (Eds.), Loss and Bereavement in Jewish Society in Israel, Joint Publisher: Canah/Ministry of Defense, 1993. (hebrew).(294 pages)

[5] Malkinson, R., Rubin, S.S. and Witztum, E. (Eds.), Traumatic and Nontraumatic Loss and Bereavement: Clinical Theory and Practice, Madison, CT: Psychosocial Press/International Universities Press, 2000

[6] Rubin, S. S, Malkinson, R., Witztum, E.(2016) The Many Faces of Loss and Bereavement: Theory and Therapy.Haifa: University of Haifa Press and Pardes. (Hebrew – Hapanim Harabot shel Ovdan Veschold: Teoriah veTipool).

[7] International Center for the Study of Loss and Bereavement, University of Haifa.

[8] Rubin, S. S., Malkinson, R., & Witztum, E., The pervasive impact of war-related loss and bereavement in Israel, International Journal of Group Tensions 28(1–2), 1999, p. 137-153.

[9] Caspi-Yavin, Y., Elements in the long term adaptability of parents who’ve lost children in war: Differences between the sexes with reaction to the loss, coping with the loss and emotional-behavioral functionality, 1987. Master’s Thesis, University of Haifa, Haifa.

[10] Kaplan L,. Loss in Traumatic Circumstances and The Two-Track Model of Bereavement: A Comparison between parents who’ve lost their children in car accidents to parent’s who’ve lost their children to suicide, 2015. Unpublished Master’s Thesis, University of Haifa, Haifa.

[11] Bar Nadav, O., Loss of a Spouse and The Two-Track Model of Bereavement: Long Term Influence of Bereavement Process in Young Women, 2007. Unpublished Doctoral Dissertation, University of Haifa, Haifa

[12] Nassar, P., Assessing children’s reaction to the loss of a parent: the influences of The Two-Track Model of Bereavement, the connection with the remaining parent, culture and profession, 2005. Unpublished Masters Thesis, University of Haifa, Haifa.

[13] Yasien-Esmael, H., Eshel, Y., & Rubin, S. S., Bereavement of Israeli Arab Muslim widows: Determinants of adjustment and supporting attributes, Death studies 42(1), 2017, p. 52-62.

[14] Rubin, S. S., Loss and mourning in the Jewish tradition, Omega 70(1), 2015, p. 79–98.

[15]Alony, M., Parents’ divorce in childhood and The Two-Track Model of Bereavement: functioning, emotional welfare and the connection with the mother as a function of divorce and the feeling of coherency in young women, 2015. Unpublished Masters Thesis, University of Haifa, Haifa.

[16] Shechory-Stahl,M., The adaptability of women whose parents had divorced when they were children and The Two-Track Model of Bereavement: the daughter’s narrative overshadowed by the mother’s narrative, 2018. Unpublished Doctoral Dissertation, University of Haifa, Haifa.

[17] Manevich, A. Attachment and The Two-Track Model of Bereavement Among Spouses of Patients with Cognitive Impairment: The Relation Between Disease Progression to Overall Functioning and the Interpersonal Relationship with the Patient, 2019. Unpublished master’s thesis. University of Haifa, Haifa, Israel.

[18] Rubin, S. S., Manevich, A., & Doron, I., I. (2019). The Two-Track Model of Dementia Grief (TTM-DG): The theoretical and clinical significance of the continuing bond in sickness and in death. Death Studies. doi:10.1080/07481187.2019.1688014

[19] Rubin, S. S., Bar-Nadav, O., Malkinson, R., Koren, D., Gofer-Shnarch, M., & Michaeli, E., The Two-Track Model of Bereavement Questionnaire (TTBQ): Development and findings of a relational measure, Death Studies 33, 2009, p. 1-29.

[20] Rubin, S.S. & Bar-Nadav, O., The Two-Track Bereavement Questionnaire for Complicated Grief (TTBQ-CG31), 2016. In R. Neimeyer (Ed.), Techniques of Grief Therapy, New York: Routledge, book 2, p.87-98,