International Society for Traumatic Stress Studies

Prolonged Grief Disorder is Getting Attention in Chinese Clinical Research and Practice

Posted 28 May 2013 in StressPoints by Suqin Tang, MA, Andreas Maercker, PhD, MD, and Jianping Wang, PhD, MD

Prolonged grief disorder (PGD) is a disturbance in which, following the death of a person close to the bereaved, there is persistent and pervasive yearning or longing for the deceased, or a persistent preoccupation with the deceased that extends beyond 6 months after the loss and that is sufficiently severe to cause significant impairment in the person’s functioning.

Background

This definition is from the latest proposal of ICD-11, for PGD (retrieved December 2012), also labelled as “complicated grief” or “traumatic grief”. In the past decade, western bereavement and mental-health experts’ attention was drawn to PGD, but little is known about this disorder in Asian cultures, especially in China.

Recently, some Chinese researchers developed an interest in this new concept, and there are already 3 Chinese reviews introducing western research on PGD. Zheng and Huang (2006) first provided a glance on complicated grief disorder to Chinese researchers. After describing theories of grief, they introduced the definition, outcomes and intervention of this pathological kind of grief. In their review, more emphasis was put on intervention advice. However, this advice is mainly designed for grief, rather than specifically for complicated grief.

Zhong and Luo (2009) took a closer look at western research on complicated grief. They gave an overview of all research aspects of complicated grief, including definition, clinical symptoms, etiology, assessment, diagnostic criteria, discrimination from normal grief, major depression and PTSD and treatment. They also discussed some inadequate aspects of current research, and suggested further research could focus on mechanisms and cultural differences. Their review is much more comprehensive than the former one, helping Chinese researchers gain a deeper understanding of what is now named PGD.

Xu and colleagues (2011) then wrote another review on diagnosis, prevention and treatment, claiming complicated grief had got a uniform concept, particular diagnostic criteria and specialized treatment, while in China there was little research and professional practice. Therefore, they suggested Chinese researchers develop the diagnostic criteria, prevention and intervention with consideration of Chinese culture. In particular, they introduced their experiences on sandplay therapy for PGD.

Thus, before going further into other aspects of PGD in China, it is necessary to get an accurate impression of bereavement and grief in Chinese culture.

Bereavement and Grief in Chinese Culture

From 2006 to 2011, the mortality rate in China increased from 8.92 million to 9.60 million (from 6.81 percent to 7.14 percent). Each year, an estimated 90 million Chinese people were confronted with the death of a significant other and this number is increasing along with the mortality rate.

The Chinese are perhaps more sensitive to the death issue (Kleinman & Kleinman, 1991). It is widely believed in Chinese culture that death will come knocking if the word “death” is mentioned, and that even the thought of the word would bring bad luck (Chow & Chan, 2006). This makes talking about death taboo in Chinese culture. The word “death” is to be avoided and is often replaced by “someone that is not here anymore.” Words that sound like “death” are avoided too. It is also taboo for children to attend funerals, as death would bring potential risks to future generations. If children ask questions about death, adults ask them to remain quiet or even go as far as punishing them (Zhong, 2009). These taboos prevent bereaved people from expressing emotions and sharing pains with family members, which may lead to more feelings of mystery, misery and fear.

On the other hand, some Chinese traditional rituals for death are believed to contribute to the recovery from the loss (Zhong, 2009). After someone has died, his or her first degree relatives immediately announce the death to all relatives and friends. They then prepare for the funeral by choosing a coffin and graveyard and making the mourning dress. These behaviours help the bereaved ones better accept the death. The funeral usually lasts a minimum of three days, and during this period the bereaved kneel and cry when someone comes to visit the dead body. These rituals are designed to help people express their grief naturally within culture norms. People may also visit the tomb on the first one hundred day, Qingming Festival, and on anniversaries to memorize the deceased person, which helps them move on with their life.

Research on Grief

Although grief is a common experience, Chinese researchers didn’t study it until 1985. In the first two decades, all researchers were from the nursing field and focusing on introducing grief theories and practice experiences abroad. Recently, psychiatrists and psychologists began empirical research on bereaved population. In their research, “bereavement” and “grief” are often used as the keywords. Bereavement refers to the experience of having lost someone close, while grief is the psychobiological response to bereavement characterized by yearning and sadness, along with thoughts, memories and images of the deceased person (Shear, 2012).

By searching the China National Knowledge Infrastructure (CNKI), the most authoritative source of China-based information resources, with keywords ”bereavement” and “grief”, we got an impression of related literature (see Table 1).

Table 1: Numbers of bereavement- or grief-related literature since 1985

Year Bereavement Grief Total
1985 - 2005 15 6 21
2006 3 14 17
2007 1 11 12
2008 5 19 24
2009 10 14 24
2010 6 8 14
2011 7 9 16
2012 2 13 15
Total 49 94 129*

*14 of these articles used both grief and bereavement as their keywords.

Most researchers conducted their studies with people who experienced the Wenchuan earthquake in 2008. The prevalence of PTSD among 159 children who lost one or both of their parents was about 25% (Guo, 2008). Wu and colleagues (2011) suggested that bereavement was a risk factor for PTSD symptoms in women. Sun and colleagues (2009) found shyness working as predictor of PTSD symptoms among 169 children around the age of 12. Li and colleagues (2011) reported that bereaved people showed a moderate level of loneliness, and suggested that good family function might relieve loneliness. For major depression patients, childhood bereavement was related to a higher likelihood of anxiety and suicidal behaviours (Yao, 2004).

Practitioners shared experiences on grief nursing for bereaved people whose relatives died from cancer (Zhang & Zhang, 2012) and parents who lost their new born child (Du & Li, 2006). Approaches of intervention varied from group counseling (He et al., 2010), rational emotive behavioral therapy (Hu & Chen, 2010), drawing (Wu, 2012), to sandplay therapy (Xu et al., 2011) and all interventions were found effective.

Research on PGD

In China, the widely used diagnostic system is neither DSM nor ICD, but Chinese Classification of Mental Disorders (CCMD), which hasn’t yet acknowledged prolonged grief (PGD) as a distinct mental disorder. There are already several Chinese publications on PGD, which can be mainly classified into reviews and interventions. Further research on diagnosis criteria and other aspects of PGD in Chinese culture is required.

Wang and Zheng (2009) presented two case studies on parents who lost their daughters in the Wenchuan earthquake in 2008. They provided supportive therapy, opportunities to express emotions and helped them balance daily life. Xu and colleagues (2011) published a case study of sandplay therapy for a bereaved 12-year-old girl with complicated grief, and found it successfully promoted her functioning by interviews and clinical observations of the therapy process. So far, there are no randomized controlled studies of psychotherapy of PGD in China.

To our knowledge, Chow and Fu from the University of Hong Kong are validating the Chinese version of the Inventory of Complicated Grief (ICG; now re-named into Inventory of Prolonged Grief: IPG), the most widely used self-report questionnaire assessing PGD. However, since people in Hong Kong speak Cantonese, rather than Mandarin of mainland China, it is necessary to develop a Mandarin version to assess Chinese population more accurately.

Conclusion

Contrary to the numerous studies on PGD in western countries, Chinese psychiatrists and psychologists are just taking the first steps in this research field. Current publications on PGD in China are mainly reviews of western research and case reports of interventions. Since Chinese culture is totally different from both western countries and other non-western countries, empirical studies in Chinese population are urgently needed.

Fortunately, some researchers from Hong Kong have begun developing a Chinese version of an assessment instrument, while other researchers from mainland China are also focusing on understanding PGD in China.

Acknowledgement: The authors wish to thank Rachel Bachem, MSc, University of Zurich, for her help with language corrections.

About the Authors

Suqin Tang, MA, is a Master of Applied Psychology (Clinical) at the Institute of Clinical and Counseling Psychology, School of Psychology, Beijing Normal University. Her interests are in the psychological mechanisms of prolonged grief disorder and Internet-based interventions for posttraumatic stress disorder. She is a core member of the Internet-based Intervention for Posttraumatic Stress Disorder Virtual Treatment Center (Sino-Swiss Science and Technology Cooperation Joint Research Project, 2008-2011) and has published 6 papers (2 in English and 4 in Chinese) and participated in translating 5 books.

Andreas Maercker, PhD, MD, is a PTSD researcher and therapist, affiliated with the University of Zurich in Switzerland. He has been collaborating with Beijing Normal University for the last decade.

Jianping Wang, PhD, MD, is professor of the School of Psychology, Beijing Normal University and vice chair of the Department of Clinical Psychology, Capital University of Medical Sciences. She is the chief editor of a number of books and an editorial board member of several leading journals. She is among the very first group of Certified Psychological Therapists and Credentialed Supervisors of Counselling and Psychotherapy and Trauma Therapists in China.

References

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Kleinman A, Kleinman J. (1991). Suffering and its professional transformation: toward an ethnography of interpersonal experience. Culture, Medicine, and Pychiatry, 15: 275-301.

Li R, Xu LWZ, Wang SP, Li XL, Dou XM, Zhu SC. (2011). Relationship between loneliness and family function among 264 bereaved cases in Wenchuan earthquake. Chinese Journal of Nursing, 26(10): 991-993.

Shear MK. (2012). Grief and mourning gone awry: pathway and course of complicated grief. Dialogues in Clinical Neuroscience, 14: 119-128.

Wang L, Zheng HM. (2009). The psychological intervention of pathological sadness. Journal of South China Normal University (social science edition), 3: 121-124, & 160.

Xu J, Chen SS, Zhang RS, Chang ML. (2011). Diagnosis, prevention and intervention of complicated grief. Chinese Journal of Clinical Psychology, 19(5): 708-710.

Xu J, Zhang RS, Chen SS, Zhang W. (2011). A case study of sandplay therapy for a bereaved girl with complicated grief. Studies of Psychology and Behaviour, 9(2): 109-114.

Zheng HX, Huang LX. (2006). Comments on complicated grief. Sichuan Mental Health, 19(4): 249-251.

Zhong MF. (2009). Discussion on the relationship of Daoism death rituals and grief therapy in Taiwan. Seasonal Journal of Taiwan Counseling, 1(2): 10-21.

Zhong AF, Luo H. (2009). Foreign research on complicated grief. Shanghai Archives of Psychiatry, 21(6): 364-366.