Investigating the mediating influence of distress tolerance on the relationship between existential thinking, sense of coherence, and the severity of mourning among families who lost a loved one to COVID‐19: A cross‐sectional study

Abstract Background and Aims The objective of the current study was to examine how distress tolerance functions as a mediator in the relationship between existential thinking, sense of coherence, and the severity of mourning experienced by families who have lost a loved one to COVID‐19. Methods The present study employed a descriptive correlational research design, targeting family members of those who passed away due to COVID‐19 in the city of Mianeh in 2022. A sample of 160 individuals was selected for statistical analysis. The research instruments used in this study consisted of Flensberg's sense of coherence questionnaire (2006), Simmons and Gaher's emotional distress tolerance questionnaire (2005), Sugbart and Scott's grief experience questionnaire (1989), and Branton Scherer's existential thinking questionnaire (2006). The collected data were analyzed using path analysis, as well as SPSS and Amos software. Results The findings of the study revealed a significant correlation coefficient between existential thinking (r = 0.465), sense of coherence (r = 0.401), and distress tolerance (r = 0.521) with the severity of mourning experienced by families who lost a loved one to COVID‐19. Moreover, the results indicated a positive and significant relationship (p > 0.01) between distress tolerance and sense of coherence (r = 0.126), as well as between distress tolerance and existential thinking (r = 0.059) among the bereaved families. However, the bootstrap test results suggested that distress tolerance did not mediate the relationship between sense of coherence and the severity of mourning in the families of COVID‐19 victims. Conclusion Consistent with prior research, the current study's findings indicated that both existential thinking and sense of coherence had a direct impact on the severity of mourning experienced by families who lost a loved one to COVID‐19. Additionally, the results revealed that the influence of existential thinking on the severity of mourning was mediated indirectly by increasing distress tolerance.

The structure of spiritual and existential thinking is considered to be one of the primary protectors of mental health during crises.
Existential thinking refers to an individual's desire to contemplate fundamental life issues, such as the meaning and purpose of life, death, emptiness, and alienation. 11Researchers suggest that exploring these existential issues may help individuals endure distress by increasing their awareness of existential issues and emphasizing the importance of discussing and reflecting on these issues. 12Furthermore, the existential attitude can stimulate healthy behaviors by encouraging individuals to search for the meaning of life and suffering. 13Studies have also demonstrated that existential thinking plays a mediating role in the relationship between death anxiety and empathy with COVID-19 patients 14 and can enhance the quality of working life for those involved in caring for dying patients. 15e lifestyle changes and intense grieving experienced by individuals who have lost loved ones due to COVID-19 have led to an increase in mental health-related problems among the family members of the deceased, which is a cause for concern.It is important to protect these survivors from the potential hardships associated with losing a loved one.However, possessing certain psychological capabilities can help reduce the duration and intensity of the grieving process, or mitigate its negative impact on an individual's life.Despite this, few studies have explored the psychological mechanisms that affect the bereavement experienced by families of COVID-19 victims, suggesting that the importance of this issue has been understudied in the field of mental health.
Therefore, there is a need for research that can shed light on the psychological factors influencing the grieving process among these families.In light of this gap in the literature, the present study was conducted to investigate the mediating role of distress tolerance in the relationship between existential thinking, sense of coherence, and the severity of mourning experienced by families who have lost a loved one to COVID-19.

| MATERIALS AND METHODS
The present study was a descriptive correlational study conducted intermittently starting from the beginning of 2022 in the city of Tabriz.The study population consisted of family members

Key points
• The severity of grief among families who lost a loved one due to Covid-19 can be affected by the psychological factors of different people.
• Existential thinking had a direct and indirect effect on the severity of grief, so existential psychotherapy can be a good help to increase psychological capacity and accelerate the process of grief treatment.
of individuals who had died due to COVID-19 in Tabriz, including spouses, parents, children, and siblings of the deceased.A purposive sampling method was employed, whereby one of the main family members of the deceased, including the spouse, child over 18 years old, father, mother, sister, or brother, was contacted and informed about the research objectives and the confidentiality of the results.A total of 160 participants completed the questionnaires in person.
To be eligible for the study, participants had to meet certain criteria, which included: the deceased must have died with a confirmed diagnosis of COVID-19 in 2022 or later; the participant must not have sought psychological help for a psychiatric disorder in the year before the incident; the participant must have had a firstdegree blood relationship with the deceased; and the participant must have provided consent to participate and complete the questionnaire.

| Distress tolerance questionnaire
Simmons and Gaher developed a self-report index consisting of 15 items and four subscales, which include emotional distress tolerance, absorption of negative emotions, estimation of mental distress, and adjustment of efforts to relieve distress.Respondents rate each item using a five-point Likert scale ranging from 1 (indicating complete agreement with the desired option) to 5 (indicating complete disagreement with the desired option).
Higher scores on the scale suggest greater distress tolerance.
The ⍺ coefficients for the subscales were 0.72, 0.82, 0.78, and 0.70, respectively, and 0.82 for the whole scale.After 6 months, the intra-class correlation was found to be 0.16.The scale also demonstrated good criterion validity and initial convergence, as indicated by previous research. 5In local research, Cronbach's ⍺ coefficient for the whole scale was 0.93, and the coefficient obtained through the retest method was 0.61. 16

| Existential thinking questionnaire
Branton Scherer developed the existential thinking questionnaire in 2006 to measure existential intelligence.The questionnaire uses a 6point Likert scale (always, almost always, often, sometimes, never, and I don't know) to assess subjects' engagement with existential concepts.The questionnaire consists of 11 items and a general subscale, and the total score ranges from 11 to 55, with higher scores indicating a greater degree of preoccupation with existential concepts.The original version of the questionnaire exhibited high reliability, with an internal consistency of 0.93.The questionnaire's single-factor structure has been supported by numerous studies. 17A local study found a Cronbach's ⍺ coefficient of 0.88 and a test−retest correlation coefficient of 0.75, indicating the questionnaire's good reliability. 11

| Grief experience questionnaire
The grief experience questionnaire, first introduced by Barrett and   Scott, consists of 34 questions designed to evaluate several aspects of bereavement.This questionnaire applies to various types of loss and death.The factors assessed include physical reactions, general grief reaction, search for an explanation, loss of support, labeling, guilt, responsibility, shame, rejection, self-destructive behavior, and unique reactions.In the original study by Barrett and Scott, the internal consistency of the questionnaire was found to be high, with a Cronbach's ⍺ coefficient of 0.97.Cronbach's ⍺ coefficients for the 11 factors were as follows: physical reactions (0.79), general grief reactions (0.68), trying to find an explanation (0.68), loss of support (0.86), being labeled (0.88), guilt (0.89), responsibility (0.88), shame (0.83), rejection (0.87), self-destructive behavior (0.79), and unique reactions (0.79). 18

| Antonevsky's sense of coherence
Antonevsky developed the abbreviated version of sense of coherence in 1987, 19 which comprises 13 items measuring three dimensions: comprehensibility (5 items), manageability (4 items), and meaningfulness (4 items).The scale uses a 5-point Likert scale, and three items are scored in reverse.Scores on this scale range from 14 to 4, with higher scores indicating greater coherence.The scale provides not only separate scores for each subscale but also an overall score.In Iran, Mohammadzadeh et al. standardized this questionnaire for Iranian students after translating it.Cronbach's ⍺ values for male and female students were 0.75 and 0.78, respectively, indicating acceptable internal consistency.The concurrent validity of this scale with the 45-item mental toughness questionnaire was 0.54.The overall scale demonstrated good test −retest reliability with a coefficient of 0.66.To assess the validity of the questionnaire, the researchers examined the relationship between the understanding, management, and meaningfulness subscales and the total score of the questionnaire.The results indicated correlations of 0.86, 0.81, and 0.76, respectively, indicating that the scale is valid and reliable. 20As shown in Table 4, there exists a significant correlation between existential thinking and distress tolerance (r = 0.059) and the severity of mourning (r = 0.465) (p < 0.01).Furthermore, sense of coherence demonstrates a positive and significant correlation with distress tolerance (r = 0.126) and the severity of mourning (r = 0.401).

| FINDINGS
Additionally, distress tolerance exhibits a positive and significant relationship with the severity of mourning (r = 0.521).
As shown in Table 5, the value of the χ 2 index is not significant (p > 0.050), and all fit indices of the model have also reached the reasonable fit criterion.Goodness of fit index and comparative fit index are above 0.90, which are reasonable for model fitness.The root mean square error of approximation was also 0.056 which is reasonable.
According to Table 6 and the paths of the model, it can be observed that sense of coherence has a significant positive direct effect on the severity of mourning among the families of the deceased from COVID-19 (β = 0.480), but it does not significantly impact distress tolerance (β = 0.007).Furthermore, existential thinking has a significant negative direct effect on the severity of mourning (β = −0.297)and a significant positive direct effect on distress tolerance (β = 0.152).Additionally, the severity of mourning has a significant negative direct effect on distress tolerance (β = −0.372).The primary objective of this investigation was to explore the potential mediating role of distress tolerance in the relationship between existential thinking, sense of coherence, and the severity of mourning in the families of individuals who passed away as a result of COVID-19.The findings indicated that only the indirect influence of existential thinking on the severity of mourning through distress tolerance was significant, while no direct effect of sense of coherence was found.The results further showed that both existential thinking and sense of coherence, as well as distress tolerance, had a direct and statistically significant impact on the severity of mourning.Furthermore, the direct impact of existential thinking on distress tolerance was also found to be significant.

According to
The research conducted by Bolen and Connor 9 investigated the correlation between sense of coherence and the severity of mourning experienced by families who lost their loved ones due to COVID-19.
The study found that attributing meaning to the events surrounding the loss can have a positive impact on bereaved individuals, which is consistent with the current research's findings regarding the relationship and direct and significant influence of sense of coherence on the severity of mourning.
Antonovsky posited that individuals with a high level of sense of coherence are less likely to experience stress and anxiety during challenging situations, and they are also less prone to disappointment and depression when facing difficult circumstances. 21Consequently, sense of coherence is considered a vital factor in promoting health and positive outcomes, and it is an effective means of coping with problems. 22In this regard, having a sense of coherence enables the families of the deceased to perceive life's internal and external stressors in an orderly, predictable, and understandable way.
The present study is in accordance with previous research that examines the direct and indirect impacts of existential thinking on the severity of mourning experienced by families of those who have passed away from Covid-19.Studies (Brassai et al., 13 Dargahi et al., 14 and Mason et al.) 15 have demonstrated that an existential mindset can promote beneficial behaviors, such as improving distress The results of the bootstrap test for the paths of distress tolerance in the relationship between sense of coherence, existential thinking, and the severity of mourning.
The model for predicting the severity of mourning (standard mode).Figure 1 shows the direct and indirect paths in the standardized model.

F I G U R E 2
The model for predicting the severity of mourning in the (significant numbers).Figure 2 shows the direct and indirect paths in the significance of numbers.
tolerance, through individuals' search for the meaning of life.
Moreover, research has suggested that existential thinking can heighten nurses' empathy toward Covid-19 patients by reducing health anxiety. 14w individuals perceive the loss of their loved ones following their passing is influenced by various factors.Individuals who engage in deep reflection are likely to exhibit greater acceptance and flexibility in coping with the loss.By confronting existential issues, individuals can develop a potential capacity for personal growth and increased awareness of the struggles associated with existence. 23is heightened awareness can lead to an increase in distress tolerance, ultimately resulting in a reduction in the severity of mourning experienced by the bereaved family members.Some studies have suggested that mediating factors, such as the meaning of life, coping strategies, and religiosity, may play a role in the relationship between existential thinking and grief-related problems. 24Giving meaning to life is a category of existential thinking that is dependent on an individual's attitude toward life. 25According to the conducted research, ascribing meaning to problems and suffering is a fundamental aspect of living purposefully, adapting to stress, and enduring distress. 26Research investigating the relationship between meaning in life and psychopathology has demonstrated that a low level of meaning in life is associated with various mental health issues, such as addiction disorders, depression, hopelessness, and suicide. 27Given the close link between existential thinking and the meaning of life, individuals who perceive life to be more meaningful are better equipped to face life's challenges, process new information, and maintain a broader and more positive outlook for their future.As such, having a sense of meaning in life and engaging in existential thinking can serve as beneficial coping mechanisms, enabling individuals to better endure difficult times, including the mourning period following the loss of loved ones.

| CONCLUSION
The present study's findings, which align with previous research, demonstrate that existential thinking can impact the severity of mourning experienced by families who have lost loved ones to Covid-19 by promoting distress tolerance.Therefore, emphasizing an existential perspective and ascribing significance to life as a psychological safeguard can assist bereaved individuals in processing and accepting their grief.

Table 1
displays the age distribution of individuals who have died from Covid-19.Based on the results obtained in Table1, it is evident that the largest number of respondents falls within the age range of 61−80 years, while the smallest number is in the under-20 age group.

Table 2
shows the frequency of the relationship between the participants with the deceased person caused by the Covid-19.

Table 7
Age distribution of the individuals who died from Covid-19.The type of relationship between the participant and the person who died from Covid-19.Descriptive statistics.Correlation matrix of the variables.Model fit indices.
passed away as a result of Covid-19.Nevertheless, the distress tolerance variable does play a mediating (indirect) role in the relationship between existential thinking and the severity of mourning experienced by the bereaved families affected by the pandemic (Figures1 and 2).T A B L E 1 T A B L E 5