Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees
Definitions of complicated grief vary across diagnostic systems, being represented as persistent complex bereavement (PCB) in DSM-5 and prolonged grief disorder (PGD) in the proposed revision of the ICD system. A past study in a high-income country has identified a six-factor structure for complicated grief, but there are no data testing this or any other model across cultures. The present study reports findings from a survey amongst West Papuan refugees (n = 230, response rate = 92 %) residing in Port Moresby, Papua New Guinea.
Materials and methods
We applied culturally adapted measures of conflict-related traumatic event (TEs) (drawing specifically on domains of conflict and loss), symptoms of complicated grief adapted and modified to the culture, and a multidimensional psychosocial index of the broader effects of conflict and displacement.
Confirmatory factor analysis yielded a single higher order construct of complicated grief comprising six factors of yearning/preoccupation; shock/disbelief; anger/negative appraisal; behavioural change; estrangement from others/impairment; and a novel dimension of confusion/diminished identity. In contrast, our analysis failed to support DSM or ICD models of PCB or PGD. A Multiple Indicators Multiple Causes (MIMIC) model revealed that traumatic loss and the sense of injustice each were associated with the unitary construct of complicated grief and its subdomains of yearning/preoccupation; shock/disbelief; anger/negative appraisal (exclusive to injustice); and estrangement from others/social impairment (exclusive to TE domain of conflict and loss).
Conflict and loss associated with feelings of injustice may be especially pathogenic in generating the anger/negative appraisal component of complicated grief amongst refugees.
KeywordsComplicated grief Prolonged grief Persistent complex bereavement Refugee ADAPT
- 8.Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, et al. (2009) Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med 6Google Scholar
- 10.American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Association Press, WashingtonGoogle Scholar
- 11.Budiardjo C, Liem S (1988) West Papua: the obliteration of a people, TapolGoogle Scholar
- 12.Brundige E, King W, Vahali P, Vladek S, Yuan X (2004) Indonesian Human Rights Abuses in West Papua: Application of the Law of Genocide to the History of Indonesian Control. Allard K. Lowenstein International Human Rights Clinic, Yale Law School, New HavenGoogle Scholar
- 13.Rees, Silove D, Tay AK, Moses K (2013) Human rights trauma and the mental health of West Papuan refugees resettled in Australia. Med J Aust 199Google Scholar
- 14.Human Rights Watch (2014) Letter to the Chair and Members of the European Parliament’s Subcommittee on Human Rights ahead of the Hearing on the Human Rights situation in West Papua and Papua provinces. Human Rights WatchGoogle Scholar
- 15.Cordell M (2013) West Papuans tortured, killed and dumped at sea, citizens’ tribunal hears. The GuardianGoogle Scholar
- 17.Silove D (2013) The ADAPT model: a conceptual framework for mental health and psychosocial programming in post conflict settings Intervention 11Google Scholar
- 22.Elsmslie J (2010) West Papuan demographic transition and the 2010 Indonesian Census: “Slow motion genocide” or not?. The West Papua project at the Centre for Peace and Conflict Studies. Centre for Peace and Conflict Studies Working Paper 11/1, The University of SydneyGoogle Scholar
- 23.Tay K, Rees S, Silove D, Chen J, Kareth M, et al (2015) Exposure to conflict-related trauma and current stressors on the mental health and functioning of West Papuan refugees in Port Moresby, Papua New Guinea (PNG). PLos One (in press)Google Scholar
- 26.Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R et al (1988) Developing instruments for cross-cultural psychiatric research. J Nerv Mental Dis 176:257–263Google Scholar
- 29.Joreskog K, Goldberger A (1975) Estimation of a model with multiple indicators and multiple causes of a single latent variable. J Am Stat Assoc 70:631–639Google Scholar
- 32.Kline RB (1998) Principles and practice of structural equation modeling. The Guilford Press, New YorkGoogle Scholar
- 33.StataCorp (2013) Stata statistical software: release 13. StataCorp LP, College stationGoogle Scholar
- 34.Muthen L, Muthen B (2014) Mplus user’s guide, 7th ed. Muthen & Muthen, Los AngelesGoogle Scholar
- 42.Murray LK, Cohen JA, Ellis BH, Mannarino A (2008) Cognitive behavioral therapy for symptoms of trauma and traumatic grief in refugee youth. Child Adolesc Psychiatr Clin N Am 17:585-604, ixGoogle Scholar
- 47.Shear, Wang Y, Skritskaya N, Duan N, Mauro C, et al. (2014) Treatment of complicated grief in elderly persons: a randomized clinical trial. JAMA PsychiatryGoogle Scholar