Upward and Downward Counterfactual Thought After Loss: A Multiwave Controlled Longitudinal Study

Maarten C. Eisma*, Kai Epstude, Henk A.W. Schut, Margaret S. Stroebe, Adriana Simion, Paul A. Boelen

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

15 Citations (Scopus)
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Counterfactual thoughts, mental simulations about how a situation may have turned out differently (i.e., “if only …, then …”), can reduce mental health after stressful life-events. However, how specific counterfactual thought types relate to post-loss mental health problems is unclear. We hypothesized that self-referenced upward counterfactuals (i.e., “If only I had done …, then the current situation would be better”) may serve as cognitive avoidance, thereby perpetuating loss-related distress. Conversely, downward counterfactuals (i.e., “If … had happened, then the current situation could have been [even] worse”) may facilitate benefit finding, thereby reducing distress. In a longitudinal survey, self-referent, other-referent, and nonreferent upward counterfactuals, and nonreferent downward counterfactuals were assessed at baseline. Prolonged grief and depression symptoms were assessed at baseline, and 6- and 12-month follow-ups. Multiple regression analyses assessed associations between counterfactual thoughts and symptom levels in 65 recently bereaved people who generated counterfactual thoughts about the loss-event. Moderator analyses assessed the unicity of significant effects in the previous step, by comparing these effects in 59 people generating loss-related counterfactuals with those in 59 propensity-score matched participants generating counterfactuals about other negative life-events. Multivariate analyses showed that nonreferent upward counterfactuals were uniquely strongly positively associated with prolonged grief and depression symptoms concurrently. Self-referent upward counterfactuals were uniquely positively associated with prolonged grief and depression symptoms longitudinally. Moderator analyses confirmed that thinking about how one's (in)actions could prevent a death uniquely exacerbated prolonged grief and depression severity. Prolonged grief treatment may be improved by targeting self-blame and guilt.

Original languageEnglish
Pages (from-to)577-593
Number of pages17
JournalBehavior Therapy
Issue number3
Publication statusPublished - May-2021


  • complicated grief
  • persistent complex bereavement disorder
  • rumination
  • coping
  • regret
  • emotion regulation

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