Commemoration of disruptive events: a scoping review about posttraumatic stress reactions and related factors.

Collective commemoration in response to war or disaster is widespread across time and cultures. It is assumed to support those affected by the disruptive event to cope with their experiences. However, the actual relationship between commemoration and mental health outcomes is complicated and evidence of healing effects remains elusive. By applying a scoping review approach, this article maps empirical studies that focus on commemoration from a psychological perspective. Within five electronic databases, 415 unique articles were identified, of which 26 met the predetermined inclusion criteria, i.e. presenting empirical data on the subject of war or large-scale violence and commemoration in relation to posttraumatic stress (PTS) and grief reactions. The data were extracted and analysed according to the five steps of a systematic scoping review. Results varied, with both negative and positive effects of commemoration on PTS and grief reactions being reported. Based on these findings we propose an evidence-informed model that distinguishes different aspects influencing the linkage between commemoration and PTS and grief reactions. The following aspects are distinguished: contextual factors, including political and cultural context, individual characteristics and facilitating mechanism, including expression, recognition, support, meaning-making and personal memories. The proposed model needs to be tested and validated by further quantitative research. This will allow social workers and policy makers to make well-informed decisions about commemorative events that may benefit fractured communities as well as individuals.

Introduction

War, genocide, and armed conflicts are a reality in this contemporary world. The emotional impact of such tragedies can be huge and long-lasting (Harlow, 2005). Commemorations are frequently organized in response to such events, among other reasons, to remember those who died (Hunt, 2010). Commemoration involves an action that arises from an ‘intention to keep the memory of a person or a thing alive’ (Bomba, 2016, p. 7). Although this can be performed both in private and in public, this article will focus on public types of commemoration. Recently, growing attention for commemoration has been observed in the Western World (Winter, 2007). Even though the Second World War (WWII) ended over seventy years ago, the number of memorials and commemoration ceremonies of WWII is still growing in the Netherlands (Walsum, 2015).

One critical aim of commemoration is to assist survivors and society as a whole in working through experiences of trauma and loss. Achieving this aim is often taken for granted. Many authors mention the importance of commemoration in coping with disruptive experiences for people directly or indirectly affected by war, genocide or disaster (Hunt, 2010; Miller, 2012; Pivnick, 2011; Veil, Sellnow, & Heald, 2011). Miller (2012) describes various ways in which commemoration can assist those affected, namely through possibilities of expression, gaining acknowledgement, and receiving social support. In psychoanalytic writings, it has been postulated that commemorations bring emotions to the surface, which enables someone to mourn and work through the experience of loss (Fogelman & Bass-Wichelhaus, 2002; Ornstein, 2010). Likewise, memorials are assumed to help families work through their traumatic memories and losses (IJzendoorn, Bakermans-Kranenburg, & Sagi-Schwartz, 2003). However, commemorating is a complicated and paradoxical issue. In societies, different opinions exist about goals of commemorations, what or who should be remembered, in which way, and for how long (Frijda, 2006; Stanley, 2015). Even those directly affected by the event, such as survivors, veterans, or citizens, often have different needs and ideas about the public commemorations for their lost loved ones (Ibreck, 2012; Pivnick & Hennes, 2014). Furthermore, while memorials intend to honour and provide space to mourn the deaths, it may also create a barrier to healing. Because of the static element of a memorial, the growth and transformation of a community cannot be represented. This may petrify the trauma narrative and therefore threaten the process of healing (Metz, 2016).

Surprisingly, empirical studies investigating the individual impact of commemoration on emotional functioning and psychosocial wellbeing is scarce and evidence remains elusive. To the authors’ knowledge, no review on this topic exists and existing research varies widely in terms of method, target group, kind of commemoration, and is conflicting in results. Through a review of the literature, the present study provides an overview in terms of volume, design, and main findings of empirical studies, concentrating on the individual impact of commemoration on posttraumatic stress (PTS) and grief reactions. The results of the included studies are synthesized and form the basis of an evidence-informed model to explain different responses towards commemoration. Insight into the impact of commemoration can guide institutions in charge of organizing and implementing commemorations after war or disaster. In addition, it can advise psychologists and social workers in their clinical practice with those affected by large-scale violence. This might benefit individuals as well as communities that have been struck by violence and upheaval.

Methods

Since the field of commemoration has hardly been studied within clinical psychology, this article is structured as a scoping review. This kind of review allows for including a wide variety of study designs as it aims at mapping key concepts and types of evidence and gaps rather than merging results into one outcome (Arksey & O’Malley, 2005; Levac, Colquhoun, & O’Brien, 2010). In this study, the five stages of a scoping review described by Arksey and O’Malley (2005) and the PRISMA-ScR checklist (Tricco et al., 2018) were used to systematically review the data.

Stage 1. Identifying the research question

The main research question is how collective commemoration after war, genocide or large-scale violence is related to the experience of PTS and grief reactions. In addition, we examine aspects that might influence (i.e. strengthen or weaken) this relationship, as presented by the reviewed studies.

Stage 2. Identifying relevant studies

The search was conducted on 2 May 2019 in five different electronic databases: PsycInfo, Medline, Evidence Based Medicine Reviews (EBMR), Published International Literature on Traumatic Stress (PILOTS) and Web of Science (WoS). The search strategy (using thesaurus terms and Boolean operators) is described in Table 1. No time frame was specified in the search strategy.

Table 1.

Search terms used.

Theme	Search terms
Event	War OR wars OR genocide* OR holocaust* OR massacre* OR mass violence OR armed conflict
Commemoration	Memorial* OR monument* OR commemorat* OR memoralisat* OR memorat*
Grief and trauma reactions	Anniversary reaction* OR anniversary event* OR bereave* OR grief OR griev* OR mourn* OR sorrow* OR loss OR ptsd OR posttraumatic OR psychological trauma OR emotional trauma OR traumatic OR troubl* memor*

Stage 3. Study selection

Through these electronic databases, we identified 415 potentially relevant articles (see Figure 1), of which 338 articles remained after duplicates were removed (Bramer, Giustini, de Jonge, Holland, & Bekhuis, 2016). Titles and abstracts of the included articles were scanned using the inclusion criteria (Table 2). The initial 97 articles (authors with surname A-D) were scanned by two of the authors (HM & TM). Agreement about including articles was reached for 90% of these articles. Differences in decisions between the reviewers were discussed until consensus was reached. One author (HM) scanned the remaining 241 articles. Reference lists of included articles were checked, based on which two additional articles were included in the review. After finishing the selection process, 26 articles were identified for review.

Figure 1.

Flow chart.

Table 2.

Inclusion criteria.

Inclusion criteria
- Examining public commemoration (including visits to public memorials and specific rituals as part of collective commemorations)
- Commemoration related to war, genocide, or mass violence
- Reflecting on posttraumatic stress or grief reactions (and/or associated emotions)
- Written in English
- Empirical basis (case study, qualitative or quantitative design)
- Humans were used as the source of information
- Published in a peer reviewed journal (to ensure quality)

Stage 4. Charting the data

As proposed by Arksey and O’Malley (2005), a data charting form was used to extract data from the included articles. Data were charted regarding the studied population, study design, type of commemoration, effect on PTS or grief reactions and factors that influenced this reaction. This facilitated the analysis and identification of overarching key variables in the studied relationship. Table 3 summarizes the included studies.

Table 3.

Summary of articles included in the review.

Author, year	Title	Studied population	Study design and data collection method (n)	Type of commemoration	Correlates	Effect on posttraumatic stress, grief, and related emotions
Commemoration of war and genocide – Related to WWII
Barron et al. (2008)	Social integration, a sense of belonging and the Cenotaph Service: Old soldiers reminisce about Remembrance	Veterans who fought in WWII and/or Korean war(directly affected)	Qualitative design, 10 focus groups (n = 45)Cross-sectional	Collective commemoration (Cenotaph Service)	- Demographic (gender)- Support (comradeship, integration in society & sense of belonging as well as feeling of isolation)- Expression (trigger to talk)- Recognition (being forgotten)- Personal memories (reminisce safely)	- Feelings of emotional distress- Bitterness- Reignite trauma- Relieve of trauma distress- Distinction between now and then
Bilewicz and Wojcik (2018)	Visiting Auschwitz: Evidence of secondary traumatization among high school students	Polish high school students (indirectly affected)	Quantitative design, survey study (n = 341)Longitudinal (3 assessments; 1 month before, directly after and 1 month follow up)Measures: Inclusion of victims in the self, PANAS, Short PTSD Inventory	School trip to Auschwitz-Birkenau	- Recognition (compassion/empathy, inclusion of others into the self)	- No significant changes in affect 1 month after trip- 13.2% of the students classified with secondary trauma after one month: 60% intrusion-related symptoms, 28.5% avoidance symptoms, 13.2% hypervigilance symptoms
Burnell, Coleman and Hunt (2010)	Coping with traumatic memories: Second World War veterans’ experiences of social support in relation to the narrative coherence of war memories	WWII veterans (directly affected)	Qualitative design, semi-structured interview study (n = 10) Cross-sectional	Collective commemoration	- Prior experiences (trauma narrative as coherent, reconciled or incoherent)- Support (societal support)- Recognition (feeling appreciated and underscores feeling misunderstood)	- Veterans with coherent narrative: Commemoration is very important- Veterans with reconciled narrative: Come to terms with experiences- Veterans with incoherent narrative: Negative perceived
Harvey, Stein and Scott (1995)	Fifty years of grief: Accounts and reported psychological reactions of Normandy invasion veterans.	American veterans who fought in Normandy(directly affected)	Qualitative design, interview study (n = 43) Cross-sectional	Collective commemoration of 50th anniversary date of Normandy invasion	- Prior experiences (trauma avoidance and long-term denial)- Support (presence of other veterans)- Expression (open up, telling stories)- Personal memories	- Grief symptoms triggered by anniversary date
Hilton (1997)	Media triggers of post-traumatic stress disorder 50 years after the Second World War	British veterans who fought in WWII (directly affected)	Qualitative design, case study(n = 2) Clinical therapy report	Watching commemoration ceremony (50th anniversary of WWII) report on television	- Prior experiences (trauma avoidance and suppression, other psychiatric distortions)- Personal memories	- Feelings of panic and restlessness at night (resolved after 2 months)- Recurrent intrusive wartime memories and flashbacks- Loss of interest in activities- Impaired concentration- Escalating distress
Jacobs (2014)	Sites of terror and the role of memory in shaping identity among first generation descendants of the Holocaust	Children of Holocaust survivors (general community)	Qualitative design, participant observation + interview study (n = 50) Cross-sectional	Visit of Nazi death camps or labour camps	- Demographic (gender) - Expression (sharing traumatic experiences)- Support (deepening bond & enhancing empathy) - Meaning-making (family narratives are given new meaning)- Personal memories (reliving atrocity narratives)	- Experience of emotions as sadness, fear and anxiety- Transmission of grief and trauma to next generation- Intensification of feelings of familial loss
Mimouni-Bloch et al. (2013)	The mental health consequences of student “Holocaust memorial journeys”	Israeli adolescents (general community)	Quantitative design, experiment with control group, study among psychiatrists (n = 50) Cross-sectionalMeasures: Diagnoses	8-day “Holocaust memorial journey” in Poland	- Prior experiences (previous psychiatric crisis, family crisis or social difficulties) - Other (traumatic event during memorial visit)	- Higher rate of mental health problems following memorial journey (including one case of PTSD) compared to control group- Minimal negative effect (such as secondary traumatization)
Musaph (1990)	Anniversary reaction as a symptom of grief in traumatized persons	Jewish WWII survivor (directly affected)	Qualitative design, case study(n = 1) Clinical therapy report	Collective commemoration day in the Netherlands	- Prior experiences (repressed grief)- Personal memories	- Anniversary reaction, physical (flu-like) symptoms of sickness (usually last for few days)- Beginning of the process of mourning
Silverman et al. (1999)	Psychological distress and symptoms of posttraumatic stress disorder in Jewish adolescents following a brief exposure to concentration camps	American Jewish high school students (15–19) (general community)	Quantitative design, survey study (n = 87) Longitudinal (4 assessments; before, follow up 1, 6 and 12 months)Measures: SCL-90-R, Mississippi Scale for PTSD, IES	Polish concentration camps visit and Holocaust memorial service in Israel		- Increase in PTSD symptoms and general psychopathology symptoms after 6 months- No long-term effects (12 months), decrease of symptoms to baseline
Commemoration of war and genocide – Vietnam
Amen (1985)	Post-Vietnam stress disorder: A metaphor for current and past life events	Vietnam veterans with PTSD(directly affected)	Qualitative design, case study, (n = 1) Clinical therapy report	Memorial Day (not attending a commemoration ceremony) with memorial visit	- Prior experiences (other stressful life events going on)- Personal memories	- Increase in frequency of nightmares (around Memorial Day)- Mental breakdown and flashbacks- Delayed PTSD
Faltus et al. (1986)	Exacerbations of post-traumatic stress disorder symptomatology in Vietnam veterans	Vietnam veterans (directly affected)	Qualitative design, case study(n = 3) Clinical therapy report	Collective commemoration, dedication of Vietnam war memorial	- Prior experiences (unresolved trauma)	- Increase in PTSD symptoms- Treatment outcome more favourable, new aspects that were previously inaccessible were discussed
Parsonset al. (1988)	A survey of the effect of the Vietnam Memorial dedication on psychiatric symptoms in Vietnam veterans.	Vietnam veterans (directly affected)	Quantitative design, experiment, 50 participants, 44 in control group (n = 94)Cross-sectionalMeasures: VESI	Collective commemoration, dedication of Vietnam war memorial	- Prior experiences (receiving treatment or not)	- Increase in PTSD symptoms- Decrease in PTSD symptoms for non-attenders- In some cases, increase in symptoms step towards therapeutic intervention with favourable outcome
Watkins et al. (2010)	The war memorial as healing environment: The psychological effect of the Vietnam veterans memorial on Vietnam war combat veterans’ posttraumatic stress disorder symptoms	Vietnam veterans with PTSD (directly affected)	Quantitative design, experiment, 32 participants, 30 in control group (n = 62)Longitudinal (3 assessments; before, follow up 1 week and 1 month)Measures: IES-R, EVVMS	Vietnam memorial visit	- Prior experiences (number of visits)- Ritual/design (memorial design leads to deep emotions)- Expression (memorial as catalyst to allow expression)	- Increase in PTSD symptoms after one visit (hyperarousal and intrusion) - Decrease in PTSD symptoms after two visits or more
Watson et al. (1995)	Effects of a Vietnam war memorial pilgrimage on veterans with posttraumatic stress disorder	Vietnam veterans with PTSD (directly affected)	Quantitative design, experiment, no control group (n = 31) Longitudinal (3 assessments; before, follow up 2 days and 6 months)Measures: Mississippi Scale for Combat-Related PTSD	Vietnam memorial visit with commemoration ceremony		- Minor short-term improvements on some PTSD symptoms- No long-term effects- For some participants positive effects, for others counterproductive
Commemoration of war and genocide – Other
Magierowsky (2016)	(A)symmetry of (Non-) memory: The missed opportunity to work through the traumatic memory of the Polish-Ukrainian ethnic conflict in Pawlokoma	Ukrainian and Poles next generations (general community)	Qualitative design, 37 in-depth interviews + 13 short interviews (n = 50) Cross-sectional	Collective one-off anniversary commemoration ceremony	- Political involvement (e.g. conflicting ideas about who is victim and who is perpetrator)- Support (no space for social bonding)- Personal memories (family/community narrative)	- No space to work through traumatic memories- Negative traumatic memories contaminate next generation
Beristain et al. (2000)	Rituals, social sharing, silence, emotions and collective memory claims in the case of the Guatemalan genocide	Victims of Guatemalan genocide (1981–1986) (directly affected)	Qualitative design, structured interview study (n = 3424) Cross-sectional	Diverse forms of commemoration (including cultural rituals and funeral rituals)	- Cultural context (e.g. influences the degree in which individuals get angry, or are driven to know the truth)- Expression (ability/inability to talk)- Meaning-making (consolidate memories)- Support (reconstruction of social support)	- Reinforce feelings of loss, anger, sense of injustice among Spanish.- Decrease in anger, sense of injustice among Mayans - Unrelated to emotional recovery from trauma- Reinforcing intense grief (in past)- Decrease of helplessness
Gasparre et al. (2010)	Cognitive and social consequences of participation in social rites: Collective coping, social support, and post-traumatic growth in the victims of Guatemala genocide	Victims of Guatemalan genocide (1960–1996) (directly affected)	Quantitative design, survey study (n = 59) Cross-sectionalMeasures: DES, IES, Way of Coping Scale, PTGI, MSPSS	Diverse forms of commemoration (including secular ceremonies, truth and reparation commissions and religious rituals)	- Cultural context- Ritual/design (type of ritual)- Expression (social sharing about traumatic event)	- Increase in intrusions- Less avoidant thoughts related to traumatic event- PTG
Olij (2005)	Trauma awareness, healing, and group counselling in secondary schools	Rwandan youth (directly affected)	Qualitative design, interviews and observation (n = not indicated) Longitudinal	Collective commemoration ceremonies	- Prior experiences (intervention on trauma awareness and counselling)	- Dramatic period with huge outbreaks of crisis- No crisis outbreaks during April ceremonies among students after intervention- Able to mourn together in dignity
Ibreck (2010)	The politics of mourning: Survivor contributions to memorials in post-genocide Rwanda	Rwandan survivor organizations (directly affected)	Qualitative design, interviews and participant observation (n = not indicated)Longitudinal (ethnographic)	Collective commemoration ceremonies and memorial visits	- Expression (able to mourn together)- Support (commitment through one another)- Recognition (for loss and suffering)- Meaning-making (acceptance of the loss)	- Reawaken sorrow, anguish and trauma- Traumatic crisis- Expression of grief and sense of relief through grief and mourning
Gishoma et al. (2015)	Remembering and re-experiencing trauma during genocide commemorations	Rwandans who experienced traumatic crisis (directly affected)	Quantitative design, experiment, 16 participants, 32 waiting list (n = 48)Longitudinal (3 assessments; before, during and after intervention)Measures: DES, UCLA Loneliness Scale, CES-D, IES-R, RS	Collective commemorations	- Prior experiences (intervention of supportive-expressive group therapy)	- Increase in traumatic crises with contagious effect
Kabakambira et al. (2018)	Burden of post-traumatic stress disorder acute exacerbations (PAE) during the commemorations of the genocide against Tutsis in Rwanda: A cross-sectional study	Rwandans with PTSD diagnoses (directly affected)	Quantitative design, retrospective survey study (n = 383)Cross-sectionalMeasures: PAE duration, presenting signs	Collective commemoration week	- Prior experiences (history of PAE, loss of partner)- Personal memories	- Severe PAE (of more than 30 minutes) among 33.2% of the patients
Pollack (2003)	Intentions of burial: Mourning, politics, and memorials following the massacre at Srebrenica	Survivors and advocacy groups of the Bosnia war (directly affected and general community)	Qualitative design, interview study with 37 survivors and 30 key-informants (n = 67)Cross-sectional	Collective re-burial of victims	- Political involvement (different goals with re-burial)- Meaning-making (acceptance and closure)- Support (opportunity to talk, grief together)- Recognition (for loss and suffering)- Personal memories	- Start process of mourning after reburial of the body- Hard to see so many graves together, prefer body buried individually
Possick et al. (2007)	Reconstructing the loss: Hantzacha commemoration following the death of a spouse in a terror attack	Israeli widows (who lost their husband in a terror attack)(directly affected)	Qualitative design, interviews (n = 8) Cross-sectional	Collective commemoration, as well as individual, with or without a memorial	- Ritual/design (type of ritual)- Meaning making (collective meaning of death as heroic and worthwhile sacrifice)	- Not as important for individual mourning as private commemoration in daily life
Zembylas and Bekerman (2011)	The work of mourning in the bilingual schools of Israel: Ambivalent emotions and the risks of seeking mutual respect and understanding	Palestinian and Jewish youth (general community)	Qualitative design, interview and observation study, 16 Palestinian, 15 Jewish and one foreign student(s) (n = 32) Longitudinal (ethnographic)	Memorial Day and Holocaust Day	- Demographic (identification with the victims)- Political involvement (state who decides who will be grieved)- Meaning-making (struggle to understand present-day suffering of Palestinian community)- Recognition (of the other communities trauma)- Personal memories (family narratives)	- Ambivalence in work of mourning - Expressing emotions of solidarity and empathy
Bensimon et al. (2016)	The emotional impact of national music on young and older adults differing in posttraumatic stress disorder symptoms	Young and old Israelites (general community)	Quantitative design, experiment, questionnaires. 144 young and 132 old participants (n = 276) Cross-sectional Questionnaire: PCL-5, SPANE	Specific ritual, listening to sad or happy national songs (related to Memorial Day or Independence Day)	- Demographic (age)- Prior experiences (severity of PTSD)	- Sad song increase negative affect - For those with low level of PTSD symptoms: Young adults more emotionally reactive than older adults- For those with high level of PTSD symptoms: Older adults more emotionally reactive than young adults
Oushakine (2006)	The politics of pity: Domesticating the loss in a Russian province	Mothers of fallen Russian soldiers (directly affected)	Qualitative design, interview and observation study (n = not indicated) Longitudinal (ethnographic)	Different kinds of commemoration, i.e. creating memorials, collective ceremonies	- Support (binding together)- Meaning-making (community of loss, resisting closure, loss is localized and contained, taking control over situation)- Recognition (highlights indifference and neglect of society, individual pain becomes collective memory)- Personal memories (continuing bonds with the deceased)	- Diminishing of individual pain- No rehabilitation, or letting go. Traumatic experience stitches their narrative together

CES-D = The Centre for Epidemiologic Studies Short Depression Scale. DES = The Izard’s Differential Emotions Scale. EVVMS = Experiencing the Vietnam Veterans Memorial Survey. IES(-R) = The Impact of Event Scale (Revised). MSPSS = The Multidimensional Scale of Perceived Social Support. PAE = PTSD Acute Exacerbations. PANAS = Positive and Negative Affect Schedule. PCL-5 = Posttraumatic checklist. PTG = posttraumatic growth. PTGI = Posttraumatic Growth Inventory. PTSD = posttraumatic stress disorder. RS = Wagnild and Young’s resilience scale. SCL-90-R = Symptom Checklist 90 items Revised. SPANE = Schedule of Positive and Negative Experience. UCLA Loneliness Scale = The University of California, Los Angeles Loneliness Scale. VESI = Vietnam Era Stress Inventory. WWII = Second World War.

Stage 5. Collating, summarizing and reporting results

A synthesis of the key variables identified in stage four resulted in an evidence- informed model. The factors in this model are discussed in detail in the Results-section.

Results

The results are structured according to the key variables that emerged while charting the data. Firstly, characteristics of the reviewed studies are described in more detail. Secondly, we elaborate on the relationship between commemoration, PTS, and grief reactions as emerging in these studies. Lastly, several correlates are presented which can be considered to influence the studied relationship. For details of the reviewed studies concerning study design and target group, we refer to Table 3.

Characteristics of the reviewed studies

Studied populations

The 26 studies included in the review were published between 1985 and 2018. Eighteen studies involved people who were directly affected by war and eight articles concentrated on the general community or second and third generation affected. Most articles focused on commemoration of WWII (n = 9). Other articles concerned commemoration of the Vietnam war (n = 5), Ukrainian-Polish conflict (n = 1), Guatemalan genocide (n = 2), Rwandan genocide (n = 4), Israeli-Palestinian conflict (n = 3), Russian wars (n = 1), and Bosnian war (n = 1).

Study design

Sixteen studies had a qualitative design, employing interviews (n = 11, of which 4 longitudinal/ethnographic), case studies (n = 4), and focus groups (n = 1). Ten studies reported a quantitative design, varying between an experimental design (n = 6, of which 3 longitudinal), and survey studies (n = 4, of which 2 longitudinal).

Type of commemoration

Eighteen studies examined collective commemoration events and 7 studies focused specifically on a memorial visit, often accompanied by a remembrance ceremony. One article concentrated on a specific ritual, namely listening to national songs linked to Memorial Day (Bensimon, Bodner, & Shrira, 2016).

Responses to commemoration

Most studies focus on PTS reactions in relation to commemoration. Grief reactions are studied to a lesser extent. There are salient differences in results between studies, pointing to an increase as well as decrease in PTS reactions.

PTS reactions

Five studies, all qualitative designs including interviews and case studies, among WWII and Vietnam veterans described clinical cases in which commemoration was linked to anniversary reactions, PTS reactions, and the onset of delayed posttraumatic stress disorder (PTSD) (Amen, 1985; Barron, Davies, & Wiggins, 2008; Faltus, Sirota, Parsons, Daamen, & Schare, 1986; Hilton, 1997; Musaph, 1990). Examples of PTS reactions reported in these studies include nightmares, flashbacks, panic attacks, and impaired concentration. Concurrently, WWII veterans in two qualitative studies highlight a relieve of trauma distress through commemoration, a distinction between now and then and a way to come to terms with experiences (Barron et al., 2008; Burnell, Coleman, & Hunt, 2010). A quantitative cross-sectional study among Guatemalan genocide survivors revealed that participating in commemoration was associated with more intrusions, and less avoidant thoughts (Gasparre, Bosco, & Bellelli, 2010). Four studies concerning commemoration of the genocide in Rwanda, with both quantitative and qualitative designs, all reported that participants of annual remembrances endured traumatic crises during and after the ceremonies (Gishoma et al., 2015; Ibreck, 2010; Kabakambira et al., 2018; Olij, 2005). Other studies (n = 3) conducted quantitative longitudinal research on the effect of visits of Vietnam veterans to the Vietnam Veterans Memorial (VVM) (Parsons, Faltus, Sirota, Schare, & Daamen, 1988; Watkins, Cole, & Weidemann, 2010; Watson, Tuorila, Detra, Gearhart, & Wielkiewicz, 1995). PTSD symptoms increased for veterans attending the dedication of the VVM, whereas a decrease in symptoms was found for veterans who did not attend the ceremony (Parsons et al., 1988). No (long-term) effects on PTSD symptoms were revealed in the other studies (Watkins et al., 2010; Watson et al., 1995), with only minor short-term improvements on some stress symptoms (Watson et al., 1995). For some participants, the trip had positive effects while the visit was counterproductive to others. Lastly, three quantitative longitudinal and experimental studies explored the impact of a Holocaust memorial visit for Polish, American Jewish and Israeli students. They revealed an initial increase of distress and PTSD symptoms (Bilewicz & Wojcik, 2018; Mimouni-Bloch, Walter, Ross, & Bloch, 2013; Silverman et al., 1999), but symptoms diminished to base line after twelve months (Silverman et al., 1999). Looking at emotions that are connected to PTS reactions, qualitative interview studies reveal that public commemoration nourished feelings of personal injustice, of being forgotten or misunderstood, which was linked to anger, bitterness, and resentment (Barron et al., 2008; Beristain, Paez, & Gonzalez, 2000; Burnell et al., 2010; Magierowski, 2016; Oushakine, 2006). The quantitative experimental study of Bensimon et al. (2016) revealed that listening to sad national songs, mainly broadcasted during Memorial Day in Israel, increased negative affect in Israeli people.

Grief reactions

Six qualitative interview studies investigated the relationship between commemoration and grief reactions. Increased feelings of grief were reported by WWII veterans from the US during the 50th anniversary commemoration ceremony (Harvey, Stein, & Scott, 1995), and by children of Holocaust survivors, visiting Nazi death camps (Jacobs, 2014). Guatemalan genocide survivors only referred to feelings of loss and intense grief as result of commemoration in the past (during the period 1981–1985) (Beristain et al., 2000). Possick et al. (2007) studied diverse, both individual and collective, commemorative activities, and interviewed Israeli widows who lost their husband in a terroristic attack. They concluded that there is only a perceived link between individual (but not collective) commemoration and mourning and grief work, whereas public commemoration serves other purposes, such as collective meaning-making. Two qualitative studies, conducting interviews among Bosnian and Rwandan genocide survivors, underline the importance of reburial to (start) the process of mourning (Ibreck, 2010; Pollack, 2003). With regard to both PTS and grief reactions, qualitative studies revealed that commemoration (re)awakened emotions of sadness, sorrow, confusion, fear, anguish, and anxiety (Ibreck, 2010; Jacobs, 2014; Musaph, 1990; Olij, 2005; Pollack, 2003; Zembylas & Bekerman, 2011).

Factors affecting the emotional consequences of commemoration

From the overview of studies, several aspects emerged that may influence how a commemoration is perceived by individuals, and therefore may influence PTS and grief reactions. These aspects can be categorized into three factors, namely facilitating mechanisms (expression, meaning-making, recognition, support, and personal memories), individual characteristics (prior experiences and demographics) and contextual factors (rituals/design, political and cultural context).

Expression

Several studies, with both qualitative and quantitative designs, showed that commemoration and visiting a memorial is linked to expression of emotions concerning the traumatic events, both through talking and non-verbal expression of feelings (Barron et al., 2008; Gasparre et al., 2010; Harvey et al., 1995; Jacobs, 2014; Watkins et al., 2010). This expression and/or sharing of emotions yielded a sense of relief (Ibreck, 2010), as well as an increase in emotions of fear, sadness, and anger (Beristain et al., 2000).

Meaning-making

Individual acceptance and meaning-making are regularly mentioned as consequences of commemoration. Qualitative studies indicated that performing rituals may foster acceptance of the loss of a loved one and closure in the process of healing (Ibreck, 2010; Pollack, 2003). Furthermore, collective remembrance is linked to attributing meaning to the loss, regaining control over life, and decreased feelings of helplessness (Beristain et al., 2000; Oushakine, 2006). From a more collective perspective, commemoration can give new meaning to family narratives (Jacobs, 2014), or advance collective memory making, in which loss and trauma can be framed as heroic and worthwhile (Beristain et al., 2000; Possick et al., 2007). Evidently, where positive meaning is made, commemoration can nourish the attribution of negative meaning as well. It can be a reminder to hold on to painful stories and victimization (Oushakine, 2006), or incomprehension about present-day sufferings (Zembylas & Bekerman, 2011).

Recognition

Related to individual acceptance, commemoration also helped people to feel acknowledged for their loss and suffering by others (Ibreck, 2010; Pollack, 2003) and to experience recognition of ones’ traumas (Zembylas & Bekerman, 2011). A side effect of this recognition, which is closely related to compassion and empathy, was illustrated by the quantitative study of Bilewicz and Wojcik (2018). They revealed an increased change of secondary traumatization among high school students with more compassion for victims, after a trip to Auschwitz. On the contrary, a group of veterans in the interview studies of Barron et al. (2008) and Burnell et al. (2010) perceived the annual commemoration in the United Kingdom as a reminder of the lack of societal recognition for their efforts. Likewise, for Russian mothers in the study of Oushakine (2006), the collective ceremonies emphasized the indifference and neglect of society.

Social support

Various qualitative studies demonstrated that commemoration had the potential to bring people together, feel united, reconstruct social support, and reduce disengagement and isolation (Barron et al., 2008; Beristain et al., 2000; Burnell et al., 2010; Harvey et al., 1995; Ibreck, 2010; Jacobs, 2014; Oushakine, 2006; Pollack, 2003). Other qualitative studies presented an opposite effect of commemoration, that is the potential to underline the absence of (societal) support or social bonding between groups (Barron et al., 2008; Magierowski, 2016).

Personal memories

The last important aspect that was derived from the reviewed studies is the emergence of personal memories through commemoration. In most articles, both quantitative and qualitative, these personal memories are described as intrusions (Amen, 1985; Harvey et al., 1995; Hilton, 1997; Kabakambira et al., 2018; Musaph, 1990; Pollack, 2003), or reliving the atrocities of family narratives for next generations (Jacobs, 2014; Zembylas & Bekerman, 2011). At the same time, personal memories may also be associated with more positive experiences. Veterans in the interview study of Barron et al. (2008) describe how commemoration can foster reminiscing of adverse events in a safe context. Further, triggered memories can assist in continuing a bond with the deceased (Oushakine, 2006). Watkins et al. (2010) hypothesized that commemoration leads to a traumatic reminder which, because of the canalized and limited form, promotes reconciliation with past experiences.

Individual characteristics

Prior experiences, especially mental health status, were most frequently reported to influence the PTS reactions in response to the commemoration. Participants from various studies, for whom commemoration yielded an increase in stress related symptoms or negative emotions, had a history of mental health problems or PTSD (e.g. Bensimon et al., 2016). Years of active avoidance and suppression of emotions related to the traumatic experience preceded the commemoration in many participants (Amen, 1985; Faltus et al., 1986; Harvey et al., 1995; Hilton, 1997; Mimouni-Bloch et al., 2013; Musaph, 1990; Parsons et al., 1988). Two qualitative studies revealed that resolving and integrating traumatic experiences, were related to a more positive experience of the commemoration (Burnell et al., 2010; Olij, 2005), although this finding was not supported by others (Gishoma et al., 2015). Personal characteristics, such as age (connected to the proximity of war and identification with victims) (Bensimon et al., 2016; Zembylas & Bekerman, 2011) or gender (Barron et al., 2008; Jacobs, 2014) are likely to influence the impact of a commemoration ceremony as well.

Contextual factors

Several qualitative studies reflect on the involvement of politics in commemorations (Magierowski, 2016; Pollack, 2003; Zembylas & Bekerman, 2011). When the state, for example, defines who is a ‘grievable person’ and who needs to be commemorated, tension may arise about the goal of commemoration as mourning or to meet political needs. Secondly, when exploring aspects that might influence the response towards commemoration, the contribution of cultural background is important to recognize as well. Specific cultural rites are indispensable in certain communities and cultures to come to terms with the loss (Ibreck, 2010; Pollack, 2003). Furthermore, culturally accepted behaviours and ways of expressing emotions may differ across cultures. As an illustration of this, Beristain et al. (2000) studied funerary rites in Mayan speaking and Spanish speaking individuals and found that these rites decreased anger and sense of injustice among the former but not the latter group (Beristain et al., 2000). The study of Gasparre et al. (2010) confirms these results; the more participants identified themselves with Mayan culture, the more they participated in rituals and experienced positive emotions. Lastly, the design of the memorial or rituals performed during the commemoration has an impact on how individuals will respond in terms of PTS or grief reactions (Gasparre et al., 2010; Possick et al., 2007; Watkins et al., 2010). Surprisingly, we identified just three studies tapping this aspect.

Structuring all findings described above resulted in a model, presented in Figure 2. The model depicts the linkage between commemoration and the increase as well as decrease of PTS and grief reactions. These responses are, in turn, affected by the described facilitating mechanisms, individual characteristics and contextual factors.

Figure 2.

Evidence-informed model of predictors of posttraumatic stress and grief reactions after commemoration.

Discussion

Collective commemorations are assumed to support individuals in coping with disruptive events. We conducted a scoping review to gain more insight in the existing empirical evidence of the relationship between collective commemoration after large-scale violence and PTS and grief reactions, as well as factors that might influence this relationship. Twenty-six empirical studies were included, on the basis of which we formulated an evidence-informed model with facilitating mechanisms, individual characteristics and contextual factors affecting responses (Figure 2). The review indicated that PTS and grief reactions often increase during and after commemoration. Individual characteristics, such as prior experiences, and contextual factors, such as the cultural and political environment, seemed to be associated with the emotional consequences of commemoration. Five other mechanisms were identified to affect individual responses, namely the degree in which people, through their involvement in commemorations, can experience support and recognition, can make meaning, express themselves, and relive personal memories.

An increase in PTS reactions through commemoration was primarily seen among directly affected individuals who suffered from PTSD or other psychiatric disorders prior to the commemoration. Considering the fact that the maintenance of PTSD is related to exposure to (nontraumatic) stressors (Schnurr, Lunney, & Sengupta, 2004), commemoration might be perceived as a stressful event and, as such, contribute to the maintenance of PTSD. It is important to note as well that the rise in stress reactions cannot be interpreted automatically as a negative outcome of commemoration. This experience can uncover suppressed emotions, start a process of mourning (Musaph, 1990), and result in a positive treatment outcome (Faltus et al., 1986; Parsons et al., 1988). Scant evidence for a decline in PTSD symptoms after commemoration was provided by the reviewed studies. Only three studies showed minor short term improvements on some stress symptoms, such as avoidant thoughts (Watkins et al., 2010; Watson et al., 1995; Gasparre et al., 2010), but at the same time an increase of intrusions was found (Gasparre et al., 2010). Feelings of grief mainly increased during times of commemoration (Harvey et al., 1995) or did not change (Beristain et al., 2000; Possick et al., 2007). From a broader emotional perspective, several primarily qualitative studies, referred to negative emotions and feelings as result of commemoration, such as sadness, anger, bitterness, and resentment (Barron et al., 2008; Beristain et al., 2000; Burnell et al., 2010; Ibreck, 2010; Jacobs, 2014; Pollack, 2003). Empathy and feelings of solidarity were mentioned as positive consequences of commemoration (Jacobs, 2014; Zembylas & Bekerman, 2011). Similar to the previous results, these findings need to be carefully interpreted: the experience and/or expression of negative emotions can have both negative and positive consequences for recovery from loss and trauma (Bonanno, Papa, Lalande, Westphal, & Coifman, 2004).

The variation in individual responses to commemoration is remarkable. It highlights the importance of exploring aspects that might influence these individual reactions. The reviewed studies revealed several aspects that might elucidate the relationship between commemoration and PTS and grief reactions. Firstly, commemoration often leads to the expression of emotions and feelings that are difficult to access in regular circumstances (Watkins et al., 2010). Prior research indicates that emotional expression tends to provide a healthy form of release (Pennebaker, Zech, & Rimé, 2001), whereas others argue that silence can be adaptive at certain stages as well (Comas-Diaz, Lykes, & Alarcon, 1998). Secondly, the reviewed studies revealed the importance of a process of meaning-making, and gaining recognition and social support through commemoration. Positive meaning-making (Feder et al., 2013; Southwick & Charney, 2018; Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000), public recognition (Summerfield, 2000), and a supportive social network (Brewin, Andrews, & Valentine, 2000) are known to support healthy recovery and protect from developing long-lasting problems after distressing events. However, commemoration can underscore a lack of recognition or societal support as well, for instance when the names of a specific group of victims are not mentioned during a commemoration. This might yield negative appraisals and meaning-making, strengthening identification with victimhood or isolation (Barron et al., 2008; Oushakine, 2006). Thirdly, a strong connection was observed between commemoration and personal reminders of the original traumatic experience, although the experimental studies did not reveal direct indicators to perceive commemoration as an effective exposure intervention (Watkins et al., 2010). Fourthly, individual characteristics, such as age, gender, and prior mental health status, are important to consider when studying the impact of commemoration. These aspects correspond to the outcomes of meta-analyses regarding risk indicators for PTSD (Brewin et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003). It is possible that commemorations can have a greater impact on people who are at higher risk to develop PTSD. Lastly, the context, including the political as well as cultural environment in which the commemoration takes place, plays a role in the individual responses to commemoration. In general, commemorative events and memorials have cultural, social, and/or political meanings and functions attached to them. The degree to which individuals agree and connect to these meanings and functions will influence how they perceive the commemoration and their emotional responses. Conflicting goals might fuel stress reactions among those involved (Magierowski, 2016). Although the studies indicate that it is important to take into account the cultural context of the studied population, no comparisons could be made in this review between the studies based on the different cohorts. The variety in backgrounds of the studied populations and the broad range of questions and methods within the studies did not allow for such a comparison.

As part of the contextual factors, the present study revealed a notable gap in the literature. Only three studies elaborated on the design of a memorial or the performed rituals as part of the commemoration. This is deemed relevant, as some rituals can be personal and open for one’s own interpretation, whereas other rituals may have a more cultural or political significance (Daines, 2000). Veil et al. (2011), adopting an artistic perspective, proposed that specific features of a memorial can shape the feelings of visitors and lead to more or less possibility to mourn. Moreover, certain rituals might effectuate individual processing, whereas others add to a process of collective recovery (Possick et al., 2007).

All the aforementioned factors demonstrate the need for a comprehensive approach that reaches beyond describing PTS and grief reactions, to be able to answer the question to whom and how commemoration can be beneficial. Commemoration gives a venue to experience several facilitators towards coping, but can emphasize the absence of these aspects as well.

Strengths and limitations

We employed an established method (see e.g. Arksey & O’Malley, 2005) for reviewing a broad scope of qualitative as well as quantitative studies. In accordance with the goal of this scoping review, the broad range of included studies provides a clear overview of the studies available in the intersection between (clinical) psychology and memory studies. This is an important first step to fill in the gap of knowledge in this field and clarify the existing empirical evidence. Including a wide variety of studies is a limitation as well. Due to the diversity in research designs and methods, a scoping review approach precludes the option to include study quality indicators, although study designs were described in Table 3 and taken into consideration throughout this review. Furthermore, the selection of studied groups, disruptive events, countries, and types of commemoration make it challenging to draw general conclusions. This emphasizes the importance of further research in this area and the need to test the proposed evidence-informed model.

Conclusion

The findings in this review might assist mental health care professionals, working with those affected by war or large-scale violence. Moreover, policy makers do well to be aware of possible negative consequences of commemoration, especially when political interest are highly involved. Further empirical data on the psychological consequences of commemoration are urgently needed to secure commemoration from a mental health perspective. As mentioned before, this could start by testing the proposed model in various contexts. A focus on specific rituals might result in a deeper understanding of the psychological impact of commemoration. The current study implies a need for a multifactorial approach when examining the impact of commemoration on mental health. This will deepen our understanding of the circumstances in which commemoration can be beneficial for individuals as well as communities that have been struck by violence and upheaval.