Toward Cultural Assessment of Grief and Grief-Related Psychopathology

The loss of loved ones can bring about manifestations of psychopathology, particularly when the loss is due to violence, accidents, or disasters, also referred to as traumatic bereavement (1). A grief disorder known as persistent complex bereavement disorder (PCBD) is included in the “Emerging Measures and Models” section of DSM-5 (2). Prolonged grief disorder (PGD), a disorder with similar symptoms, is included in the 11th edition of the International Classification of Diseases (ICD-11) (1). Besides these specific grief-related disorders, bereaved individuals may develop symptoms consistent with a diagnosis of major depressive disorder, posttraumatic stress disorder (PTSD), or both (1,2).

How one deals with bereavement and grief is influenced by the norms of one’s cultural identity. Consistent with this notion, the DSM-5 criteria for a PCBD diagnosis state, “The bereavement reaction is out of proportion to or inconsistent with cultural, religious, or age-appropriate norms.” A section on culture-related issues pertinent to the diagnosis states, “Diagnosis of the disorder requires that the persistent and severe responses go beyond cultural norms of grief responses and not be better explained by culturally specific mourning rituals.” Cultural assessment of bereavement and grief is therefore pivotal for a comprehensive evaluation of grief-related mental health.

Impact of Culture on Bereavement and Grief

Culture affects every clinical encounter (3). The impact of culture on mental health care involves not only the interactions between patient and care provider but also idioms of distress and explanatory models and even patient perceptions of what types of treatment are acceptable. Therefore, the American Psychiatric Association’s DSM-5 cross-cultural issues subgroup developed the Cultural Formulation Interview (CFI) for routine use in the clinical assessment of any patient (3). The CFI instruments comprise an initial assessment interview and 12 supplementary modules that cover the following topics: explanatory model; level of functioning; social network; psychosocial stressors; spirituality, religion, and moral traditions; cultural identity; coping and help seeking; patient-clinician relationship; school-age children and adolescents; older adults; immigrants and refugees; and caregivers. Neither the CFI nor any of these modules explicitly focus on cultural aspects related to the loss of loved ones.

Individuals and communities with immigrant, minority, and indigenous backgrounds may be particularly affected by cultural dominance and its association with historical trauma, loss, and grief through generations (4). Cultural beliefs, world views, and practices are likely to be influenced by migration, acculturation, and cultural dominance. Specifically, individuals from immigrant, minority, or indigenous groups may experience cultural incongruity arising from dissimilarity between the beliefs, expectations, and practices in the culture of origin and the dominant culture (5). Cultural dominance and incongruity may both contribute to detachment, estrangement, and distrust—phenomena that may exacerbate PCBD and PGD—as well as PTSD—following bereavement. In addition, the impossibility of performing culturally appropriate rituals related to death or mourning is often characteristic of traumatic losses of loved ones. This, too, may influence symptoms of PCBD or PGD and PTSD (6). For example, dreams about a deceased family member may evoke painful memories and guilt feelings among Cambodian survivors of the Khmer Rouge regime. A complex cultural belief system links such dreams to concerns about the spiritual status of the deceased in the afterlife. After having such dreams, survivors may want to perform various rituals to promote an auspicious rebirth of the deceased (6).

The cultural context of losing a loved one interacts with social and psychological factors. For example, the importance of certain family relationships may vary culturally. When an only son is lost, the impact on the bereaved parents may be even more devastating in the context of a patriarchal culture (7). Also, cultural rules surrounding inheritance and remarriage influence the bereaved person’s possibilities to build new roles, identities, and relationships (7).

Forced migration often implies that people had no choice but to leave behind their loved ones. In some cases, people may have witnessed or learned about the death of loved ones, but because of the unexpected and sudden nature of their departure, the fate of some loved ones may be unknown. This situation, characterized as ambiguous loss, is faced by relatives of missing persons and often occurs following forced migration. Symptoms of PCBD or PGD, PTSD, and major depressive disorder may accompany ambiguous loss (1). Unlike loss due to death, the irreversibility of ambiguous loss is not self-evident. Dealing with ambiguous loss is often complicated by judicial, financial, and family issues as well as by inability to perform leave taking and other rituals that may facilitate coping.

Cultural Assessment of Grief

Cultural assessment of grief among patients seeking mental health care following the loss of loved ones, specifically patients with presumed trauma- or grief-related disorders, is important for several reasons. First, it helps the clinician in forming hypotheses about the role of bereavement in the onset of mental disorders and whether the presentation constitutes psychopathology as opposed to, for example, normal grieving. As such, cultural assessment of grief helps clinicians to understand the cultural and religious norms relevant to the descriptions of both PCBD in DSM-5 and PGD in ICD-11. Second, it facilitates exploration of the psychological burden related to not having been able to perform meaningful death rituals. This may include the assessment of the role of missing persons as well as the influence of cultural traditions and beliefs about the afterlife in maintaining or exacerbating distress.

Third, cultural assessment helps to clarify the individual’s expectations about what types of help may be appropriate and the duration of treatment (3,8). Fourth, it contributes to developing a shared cultural understanding of bereavement and grief—a common ground, so to speak—which in turn facilitates shared decision making regarding treatment interventions, including specific psychological and psychopharmacological interventions, the choice to involve important others in the treatment, and integration of culturally appropriate rituals. Fifth, cultural interviewing is likely to enhance rapport and treatment motivation (8).

To identify existing cultural assessments related to bereavement and grief for clinical use among persons seeking mental health care, we performed a systematic search of literature published before December 2017 by using Ovid databases Embase, Medline, and PsycINFO. Search terms were death OR mourning OR grief OR bereavement OR loss AND cultural AND formulation OR interview. After removal of duplicates, the search yielded 428 records. Of these, 394 were excluded because they were not primarily about grief following the loss of loved ones, 27 because they were nonclinical studies on grief in specific groups, and six because they were studies on epidemiology, standardized diagnostic instruments, or treatment of grief-related disorders. Only one record concerned a clinical cultural interview related to bereavement and grief, and therefore it was selected to provide a possible basis for cultural assessment of grief (9). The selected study, by Eisenbruch (9), describes the Cultural Bereavement Interview for the clinical assessment of refugee distress resulting from losses of loved ones, country, and culture. It discusses perceptions of the past, visitations from ghosts or spirits in dreams, guilt feelings, personal experience of death, funerals and graves, absence of leave taking, anger and ambivalence, and religious beliefs and practices.

A Supplement to the DSM-5 CFI

Cultural assessment of bereavement and grief should complement rather than duplicate information elicited during diagnostic interviewing. Therefore, the assessment should focus beyond symptoms of grief-related disorders, biographical details, and history of trauma and loss to include cultural ways of dealing with bereavement and grief, especially those that influence adaptation to loss and therefore may be relevant for treatment. The assessment should be suitable for use in early stages of the process of care, validating diagnostic assessment and supporting treatment negotiation.

We propose adoption of a bereavement and grief supplementary module to the DSM-5 CFI that can be used as a tool for in-depth cultural assessment of bereavement and grief among patients with presumed grief-related psychopathology. We intend for the assessment to be both more focused and more generally applicable compared with the Cultural Bereavement Interview. The goal of the module is to facilitate the assessment of cultural ways of dealing with bereavement and grief among patients from any cultural background or with any cultural identity. The proposed module should be considered a draft subject to modification based on results of pilot studies evaluating its feasibility, acceptability, and clinical utility (10). [A draft of the module is available as an online supplement to this column.]

Modeled after the existing DSM-5 CFI instruments, the proposed bereavement and grief supplementary module consists of brief, person-centered, and open-ended questions mapping cultural ways of dealing with bereavement and grief. The module discusses cultural traditions related to death, bereavement, and mourning and concludes by exploring help seeking and coping related to the loss of loved ones. It includes prompts enabling the clinician to maintain the natural flow of conversation and to make adaptations for patients with limited language skills if necessary. Using these questions, the clinician may explore cultural aspects of bereavement and grief among patients seeking mental health care following the loss of loved ones in order to enhance understanding as well as tailor interventions to alleviate distress.

To this aim, the module addresses the following two topics.

Death, bereavement, and mourning.

A key function of death-related rituals is to provide structured ways to mourn and express grief. Rituals may include time frames for immediate mourning and actions to be completed at specific points thereafter (such as a wake or yearly commemoration), prescribe how to handle and dispose of the body of the deceased, and indicate when and in what way it is appropriate to talk about the deceased (7). Encounters with the deceased that may occur in dreams or when bereaved persons report having seen, felt, smelled, or talked with the deceased may have cultural explanations. The person may experience exhortation, a feeling of being strongly encouraged or urged by the deceased to perform specific actions. Also, the person may interpret the dream as evidence that the deceased is in a dire spiritual state, indicating the need to make merit—e.g., to make offerings—and perform appropriate rituals (6,9). Many death rituals allow the bereaved to settle accounts or convey apologies or gratitude to the deceased. Mourning rituals are often piacular, meaning that not performing them creates guilt. Some rituals may be thought of as having implications for the afterlife. More generally, performing prescribed rituals may be necessary for proper role fulfillment, assuring a good spiritual status of the deceased, or an auspicious rebirth (6). Within many religions, the mode of death, e.g., suicide, has implications for the afterlife (7).

Help seeking and coping.

Many bereaved individuals engage in practices related to spiritual, religious, or moral traditions to cope with the loss of a loved one, such as prayer, meditation, or other practices. In addition, they may participate in worship or religious gatherings and speak with other people in their religious group or with religious or spiritual leaders. Spiritual, moral, or religious practices and activities may be perceived as helpful in coping with the loss, especially in dealing with guilt feelings. Survivor guilt frequently occurs among traumatically bereaved survivors, notably refugees, and may be linked to cultural concepts of fairness and fate, sometime involving past and future incarnations (6,7,9). Family, friends, or others may have suggested other kinds of help. For clinicians, it is essential to explore these as well as other kinds of help considered useful by the patient for dealing with the loss of a loved one.