Understanding the role of guilt in adjustment to bereavement is complicated by the fact that guilt incorporates a variety of cognitive and emotional components , suggesting the need for finer-grained examination. The present study focuses on two components of guilt, namely, self-blame and regret. There are good reasons to select these two: They are the most-frequently identified forms of guilt in the bereavement literature (reviewed below), yet systematic comparisons of their impact have so far been lacking. Given the specific characteristics of self-blame and regret, one might assume that they have different associations with psychological well-being among bereaved persons: Self-blame and regret are close, yet distinct phenomena, ones which may play different roles in the adaptation process after loss.
To elaborate: Self-blame in the bereavement literature usually refers to making self-attributions about the cause of the death (e.g.,), and a sense of culpability due to failure to live up to standards of the deceased or one's self ,. Regret has been identified in the general literature as involving painful thoughts and feelings about past actions and how one could have achieved a better outcome , and in the bereavement specific literature, as feelings associated with unfinished business with the deceased in general , or the perception that one could have done things differently . Accordingly, we define regret in the context of bereavement, as a negative emotion accompanied by the belief that one could have done something differently to bring about a more desirable outcome with respect to the relationship with the deceased and/or the death-related events.
As evident from the above definitions, while self-blame stresses responsibility for the death, and implies accusation of oneself, regret in bereavement focuses more on possible better outcomes, without impaired sense of self. Negative cognition focused on oneself, as in self-blame, has been suggested to play a more detrimental role in psychological well-being ,, and adjustment in grief  than negative perception of one's behaviour or the event per se, as in regret. A major purpose of the current longitudinal investigation is, then, to compare the role of self-blame with that of regret in the process of coming to terms with the loss of a loved one. We examine their role not only as determinants but also their course over time, across the months of acute grief and grieving.
Next we examine the extent to which relationships between these two phenomena and health outcomes have been established so far in the bereavement literature.
The role of self-blame in bereavement
Some studies have reported a negative influence of self-blame on grieving people's well-being. Associations between these variables have been found in some cross-sectional studies. Hazzard et al.  conducted a study among bereaved parents and concluded that higher self-blame for the death was associated with more intense grief reactions, as measured using the Grief Experiences Inventory . However, this study included only one item to measure participants' self-blame for the death, raising concerns about the reliability and validity of their assessments of self-blame and resulting conclusions. Using a somewhat better measure, Garnefski and Kraaij  adopted the self-blame subscale from an emotion regulation scale to investigate the concurrent relationship between self-blame in bereavement and depressive symptoms. These investigators also found positive correlations between these variables.
Relating self-blame to a somewhat different measure of the course of grief, in two earlier studies by Weinberg ,, participants were asked to indicate their level of “recovery” from their loss: to what extent they thought they had “got over” the death. Participants who blamed themselves more for the death also reported poorer recovery. Again, these studies also relied on single item measures at a single time-point.
More recently, adopting a measure with better psychometric properties, the self-blame subscale of the Grief Cognition Questionnaire, Boelen and colleagues , found that higher self-blame was correlated with higher psychological distress (using the depression subscale of the SCL and anxiety subscales of the SCL-90), as well as more severe grief reactions (on an established grief scale, see ). However, these investigations were also cross-sectional, so no statements could be made about the impact of self-blame on grief (or vice versa).
The strongest evidence comes from longitudinal investigations, given that causal connections can be more firmly established than in cross-sectional ones. The available longitudinal studies have focused on whether self-blame during the early stages of bereavement predicts later adjustment. In a classic early study by Horowitz et al , attributions of blame for the death were investigated. Bereaved adult children with severe grief who had sought (and were receiving) treatment were compared with a bereaved non-patient, so-called “field”, control group. Participants' self-blame and psychological distress were evaluated over time until just over a year after loss. Psychological distress was assessed using a battery of symptom measures, including clinicians' ratings and scales such as the SCL-90 and Impact of Event Scale. Those who attributed more responsibility for the death to themselves, showed a slower decline in psychological symptoms, the effect being stronger for patients than field participants . This study investigated self-blame as a predictor, not its course over time. Thus, only self-blame assessed at the first point in time was used to predict the decline of psychological distress. Furthermore, only general mental health, but not grief reactions, was examined. Finally, a point which applies to studies using the total SCL, is that this symptoms list contains two (or one, in short versions) items on guilt: blaming oneself for a variety of things and feeling guilty. So, unless excluded (to our knowledge only Boelen et al.  did so), there is conceptual overlap between this and guilt measures, which would increase the likelihood of a positive relationship being found between these variables.
Two more recent studies by Field and colleagues, using a very different methodology, have provided further evidence regarding the predictive value of self-blame on adjustment to bereavement ,. Field et al. examined the content of bereaved spouses' monologues directed toward the deceased, 3–7 months after the death . A higher degree of self-blame as coded from the spouses' narratives predicted higher grief symptoms (but not depression) at 14 months. In the Field and Bonanno follow-up investigation, it was found that self-blame 6 months after bereavement predicted grief symptoms as long as 5 years after the loss . These studies were stringent in controlling for symptom levels at the first point of measurement. However, their index of self-blame was based on judges' assessments and not psychometrically-tested rating scales.
Not only are there methodological limitations in studies claiming a relationship between bereaved peoples' self-blame and general psychological distress, but some researchers have failed to find a negative influence between these two variables. Downey, Silver, and Wortman traced a group of bereaved parents at one, three and 18 months after the death of their child . The concurrent correlation between self-blame and psychological distress (as measured on a shortened version of the SCL-90) was significant, while the longitudinal association was not. This included the entire depression subscale, which again contains one item on guilt (which was not deleted). Downey and colleagues concluded that there was no causal relationship between self-blame and maladjustment in bereavement. It is possible that self-blame was assessed too early in their study to have predictive validity, since it is common for people to experience high distress and negative cognitions soon after the death, which attenuate with time . In fact, most of the studies assessed self-blame after at least 6 months. It is also noteworthy that the measure was not grief-specific but one “indexing generalized distress” (p. 929). By contrast, another more recent study compared people diagnosed with complicated grief with a group of healthy controls . Here too, though, when self-blame was the focus, no significant difference between these groups was found. The study was cross-sectional. Taken together, the negative results reported in these investigations do not provide strong evidence against the hypothesis that self-blame is associated with higher general symptomatology or grief.
The role of regret in bereavement
Two cross-sectional studies , have reported positive association between regret and psychological distress (including depression), and grief. However, both of these investigations combined items of regret and self-blame into one measure, thus giving little information on the unique role of regret. Moreover, only Japanese participants were included in these studies, which - while usefully extending investigation to another culture - raises the question about comparability of their findings with those of other studies, which have typically been conducted in western countries.
ConclusionsIn summary, the results on the role of either self-blame or regret in bereavement have been quite discrepant, making it difficult to draw overall conclusions from the available literature. With respect to self-blame: Some investigations have suggested that it impacts on grief, with perhaps the strongest evidence coming from the Field studies,. A relationship between self-blame and more general symptoms (depression in this study) was not found by these investigators, but others, such as Horowitz et al. , have found associations between such variables. Turning to regret: There are some indications of an association of regret with depression and with grief reactions, but firm conclusions are difficult to draw from the sparse literature specifically on regret.
In general, longitudinal investigation on the impact of either self-blame or regret on adjustment to bereavement has been scarce. The few available investigations over time have measurement shortcomings (e.g. single item measure and mixed items of self-blame and regret). Another shortcoming (linked to the general lack of longitudinal studies) is the paucity of information on the course of the self-blame and regret manifestations over time, for example, regarding whether they actually decline. Finally, some investigations have focused on grief-specific, others on more generic (e.g., depression) outcome variables with possible overlap of guilt in the latter studies. Although sadness and depression are important symptoms of grieving, they are neither the only nor necessarily the most important ones. There is some evidence that depression and grief are influenced by different aspects of the marital relationship. For example, Stroebe, Abakoumkin and Stroebe found that marital quality affected only yearning for the loved one who died, but not depression, whereas experiencing support from family and friends reduced depression but did not ameliorate yearning. Therefore, there seem to be good reasons to include both types of outcome variables within one investigation.
**If you or someone you know is coping with feelings of guilt after losing a loved one please contact Therese Schmoll, M.A., LMFT, MFC50082, at 310-281-6977 today, for a consultation
***For more information about the Present Study taking place visit: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0096606
Stroebe M, Stroebe W, van de Schoot R, Schut H, Abakoumkin G, Li J (2014) Guilt in Bereavement: The Role of Self-Blame and Regret in Coping with Loss. PLoS ONE 9(5): e96606. https://doi.org/10.1371/journal.pone.0096606