Grief, Bereavement and Meaning Making in Older People

Views from Rural China

Haimin Pan

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780367433376
• eBook ISBN: 9781000032482
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Spousal bereavement seems to be one of the most devastating things a person can suffer through during the course of his or her life and it can result in adverse bio-psycho-social consequences for the left behind spouse. This book offers updated views from incorporating meaning making theory and social constructionist theory to examine the mediating roles of meaning making and help readers to understand grief and bereavement experiences of the widowed elderly population in China. The volume starts with elaborating on the meaning making model, followed by an overview of grief theories and traditional culture, including empirical feedback of the results of applying the model to Chinese elderly widows and widowers. Pan's book concludes with a discussion on the implications and limitations of this research as well as future directions.

The volume provides valuable theoretical reflection and empirical evidence on grief and bereavement experiences of the elderly population in China. By combining meaning making theory with a social constructionist perspective, this research develops a novel approach to apply Western models and theories to the Chinese context and effectively study China's elderly population and their grief and bereavement experiences. This volume brings the readers the benefits of understanding Chinese cultural doctrines regarding death and life, getting a comprehensive view on meaning making theory, as well as learning the specific coping skills of Chinese elderly in widowhood.

This volume merits the attention of those in the fields of mental health, social work, and gerontology to help further their understanding of meaning making systems in a non-western setting.

1 Background on grief

1.1 Empirical background

Older generations experience many changes and transitions in later life. When a person becomes older, he/she is likely to go through many changes in the form of loss. Spousal bereavement seems to be one of the most devastating losses in the life course, and, particularly among elders, can result in adverse consequences bio-psycho-socially (van Baarsen, 2002). However, research in Chinese culture, where people are constrained in expressing their thoughts and feelings to the public, is limited, compared to the abundant Western literature on other cultural experiences (Moats, 2010). This study aims to unearth the unknown surrounding spousal grief among older people in rural China, beginning by presenting background information and outlining the contribution of this study.

1.1.1 Chinese context as the target

Although the experience of grief is common among people, the experience varies from person to person in different aspects. Personal characteristics or experiences (e.g. gender, relationship, the time elapsed since death) are associated with the outcomes of grief (Jordan & Neimeyer, 2003). For instance, men are more likely to have physical health problems and die shortly after the death of their spouse than women (Hooyman & Kramer, 2006). However, grief is also susceptible to the surrounding society, varying greatly from culture to culture. Reactions to loss are obviously closely associated with other factors including the understanding of death in the culture and death rituals that people in different cultural contexts may perform in distinct patterns. For instance, the Western idea about how they are independent is relatively meaningless to people from Eastern cultures, where people tend to have collective ways of thinking (Thompson, 2012). Grief is not a simple biological or developmental process; rather, it results from a sociocultural process (Rosenblatt, 2001). Confucianism, the mainstream ideology in Chinese culture, which emphasises filial piety, has configured a unique way to respond to and cope with grief experience. In the traditional Chinese culture, the dead always becomes a “ghost” and draws respect from descendants, yet, is seldom mentioned. The Chinese people place more importance on the existing reality of life than the afterlife (Chen, 2012), which is to an extent different from the Western religious thoughts. Studies on bereavement in Western countries outnumber those conducted in China and the available knowledge about bereavement experiences is limited. However, the less frequent mentioning of death in public among Chinese people does not mean that bereavement plays a less crucial role in their lives.

Chinese people in bereavement are also subjective to psychological burden. According to the study of He and her colleagues (2014a), Chinese people also suffer from depression, anxiety, and complicated grief when they deal with the death of a significant one. Likewise, when there was a disastrous earthquake in the year of 2008 in Wenchuan city, researchers Li, Chow, Shi, and Chan (2015) conducted a preliminary study about the prevalence of “complicated grief” (a type of psychological distress that is “against the reality of loss and generally reluctant to make the adaptations to life in the absence of the loved one”) (Prigerson et al., 2008, as cited by Supiano & Luptak, 2013) and related risk factors among the Chinese people who were affected by the earthquake. They found that 71.1% of the bereaved survivors (N = 803) were diagnosed with “complicated grief”. Such a high population struck by a disaster warranted specific attention and the provision of professional services to those who had suffered. Apart from the aforementioned information, to the best of our knowledge, little research in the Chinese context seems to have been conducted on this realm within the topic of bereavement and grief. In fact, bereaved Chinese people for myriad of reasons tend to undergo an inner struggle. On one hand, it is natural for bereaved people to experience negative sentiments and share such feelings with their friends and family. They might also rely on people for support. For example, a study conducted in Hong Kong, a cosmopolitan city where most of the population is Chinese (Chow & Yip, 2011), revealed the effects of social networks of friends on bereavement outcomes (Chow, 2006). However, culturally, most Chinese choose to suppress their true feelings due to the culture rather than expressing them in a straightforward way as Western people do (Chu, 2015; Moats, 2010). The paradox between the internal world of the bereaved and their external constraints might contribute to the veiled way in which Chinese people handle their grief. There are many who grieve in Mainland China, who struggle with severe grief-related bio-psycho-social symptoms and are waiting for assistance from people who specialise in this area of grief and bereavement, even though they may superficially act as if they have accepted their loss. Consequently, unlike Westerners who would consider counselling after losing a beloved one, Chinese people are less likely to proactively get psychological help relating to a loss, and the referral rate for counselling among Chinese communities is relatively much lower than that among Western citizens (Tsui, 2004). For example, in the United States, the referral rate for bereavement service utilisation was estimated to be 10%–35% (Bergman, 2008) while among Asians, it was only 5% (Tsui, 2004).

In addition, in Chinese culture, it is traditional to not visit a friend’s home or engage in any celebratory activity for at least 100 days after a death (Chan & Mak, 2000). Widows, for example, are sometimes looked down upon by family members, because they are labelled by them as being unlucky. Therefore, within the first year of a widow’s bereavement, they are not usually welcome at happy occasions such as birthdays or weddings (Chan et al., 2005). Withdrawal from social activity may have a backlash in the time of intensive grief given that social support is important in helping bereaved individuals to handle their grief (Stroebe, Folkman, Hansson, & Schut, 2006), particularly support from relatives (Pui, 2014). Overall, bereaved Chinese demonstrate a different and unique way to cope with the death of a loved one when compared to Westerners in terms of grieving. In reality, the phenomenon of grief has attracted much attention from researchers in Western backgrounds. However, research on grief and bereavement in the Chinese context is sparse. The dearth of evidence on grief in the Chinese context, as well as its negative outcomes and unique demonstration among Chinese people, underlines the value of this study.

1.1.2 The prevalence of widowhood or spousal bereavement in China

The high proportion of the widowed older population has attracted the attention of researchers in this field. Because of longer life expectancy and lower birth rates in China, the proportion of the older population is expanding, and so is the widowed population. In Hong Kong, the proportion of older widowed adults was reported to be about 31.0%, reaching 292,219, of which 16.4% (47,901) were men and 83.6% (244,318) were women (Hong Kong Government, 2011). The growth rate of the total widowed population from 2006 to 2011 was about 7.6%, a little higher than that of the period 2001–2006 by 0.4%. Yet, both were much higher than the average annual rate of increase in the number of older persons corresponding to the time, which was 2.0% and 2.5%, respectively. In Mainland China, people who are aged 60 or above are officially referred to as the older group. According to the Ministry of Civil Affairs of the People’s Republic of China (2017), there are approximately 150.03 million older people aged 65 or over in Mainland China, comprising 10.8% of the total population by the end of 2016. In the trend of rapid population aging, a large number of elders will experience spousal bereavement in the coming decades. In 2010, about 26.89% of older people aged 60 or above, nearly 4.75 million, were in a state of spousal bereavement (Population Census Office under the State Council, 2012). Among the older widowed population, their cumulative spousal bereavement probability increases with age according to Jiang, Li, and Sánchez-Barricarte (2015) (see Figure 1.1). When a man reaches age 60, his spousal bereavement probability approaches 0.05. In other words, his spouse has a mortality risk of 0.05 before he reaches 60. By contrast, for a woman, this likelihood leaps to 0.15. In the coming decades, the number of aging people will rise increasingly quickly. Wang and Ge (2013) predicted that the total widowed older population would reach 118.40 million by 2050, of which 23.91 million would be men and 94.49 million women.

Figure 1.1 Cumulative spousal bereavement probability by age in China

(Jiang, Li, & Sánchez-Barricarte, 2015)

The loss of a spouse may happen quickly, but its impact on the survivor can last for a long time after the event. For example, older people in spousal bereavement count as a high-risk group in terms of suffering from “complicated grief” that leads to impairments of functions in daily life. That increased likelihood was affirmed by Newson, Boelen, Hek, Hofman, and Tiemeier (2011) in a study illustrating that 4.8% of a sample containing 5,741 older adults had “complicated grief”, and that those who were spousally bereaved presented a 2.42 times increased risk of complicated grief. Clearly, there is an urgency to give attention to the needs of this growing group of widowed elders in China.

1.1.3 The influence of grief experience

Although most losses mark an inevitable phase of old age, it can still be stressful and devastating for older adults to deal with. Bereaved people have been reported to have worsened physical conditions in the early months after the loss, a risk that was estimated to be 1.4 times higher than for non-bereaved people, while the self-reported use of medication was reported to be 1.73 times greater (Thompson, Breckenridge, Gallagher, & Peterson, 1984). The findings are similar to those of a study by Buckley and co-workers (2012), which concluded that changes of an inflammatory and thrombotic nature might lead to increased risk of cardiovascular disease in early bereavement among bereaved spouses. Also, many studies have found a decline in the mental health of bereaved adults (Damianakis & Marziali, 2012; Li et al., 2015; Shear, Ghesquiere, & Glickman, 2013), including depression, anxiety disorder, and post-traumatic stress disorder (PTSD) as well as alcohol abuse, suicidal ideation (Harwood, 2001), and sleep disturbance (Richardson, Lund, Caserta, Dudley, & Obray, 2003).

Apart from the physical impact, psychological distress should be of concern as well. Most distressing is the consistent finding of an excessive mortality rate of bereaved persons (Stroebe & Stroebe, 1993). A partner may play many roles in life, such as those of a lover, a companion, and a best friend, so that the death not only deprives someone of that person, but also of the secondary loss incurred by the death. Older bereaved adults might lose the emotional and instrumental social support formerly rendered by the spouse. Social life and daily routines are disrupted when the spouse is no longer there. In particular, Gallagher-Thompson, Futterman, Farberow, Thompson, and Peterson (1993) found loneliness to be most relevant to the after-bereavement life of older widowed adults, while older people who lived with a spouse would have greater life satisfaction than those who did not (Chipperfield & Havens, 2001). The multidimensional adverse effect of bereavement not only affects the older widowed adult but also family members. Adult children of the elderly in bereavement grieve twice: once over the loss of one parent through actual death and a second time over the loss of the other as a well-functioning widowed parent. Therefore, intervention in this field is clinically desirable and at least needs to attempt to address this group of co-morbid symptoms (Barbosa, Sá, & Rocha, 2014).

In view of the negative impacts of bereavement, action taken to relieve the pain for the bereaved deserves consideration. On a positive note, many programs and services (e.g. cognitive behavioural therapy and narrative therapy) for bereavement have been developed to meet the needs of people grieving globally (Hedtke, 2014; Rosner, Pfoh, Kotoučová, & Hagl, 2014). However, there is still great room for improvement of the service system, particularly in Mainland China, where the system of public welfare is less sophisticated than that in Hong Kong. Meaning making—cognitive strategies used to reinterpret the meaning of a situation (Boehmer, Luszczynska, & Schwarzer, 2007)—serves as an alternative approach for researchers and practitioners to delve into the natural response to the loss of spouses and thus obtain theoretical and practical hints from its implications. The relationship between meaning making and cognitive behavioural therapy and narrative therapy is to assist in tackling these negative events. Notably, Neimeyer and Hogan (2001) conduct both a quantitative and qualitative study, providing in-depth information about how elders react to their loss in their after-bereavement life in the Chinese culture.

Bereavement is a common life experience among human beings, but it varies from person to person and from culture to culture. In this present study, the qualitative method additionally explores an in-depth understanding of grief experienced by Chinese elders by using the grounded theory method. It unfolds the uniqueness of bereavement in relation to Chinese culture. Rubin and Schechter (1997) state that time is a significant factor in adjusting to a loss. Hence, the qualitative information sheds light on the specificity of spousal bereavement in older rural Chinese people at certain time points.

1.1.4 The target group of older people

Older people are the target as the generation for research based on the following reasons. While grief is a common and inevitable experience in life for everyone, compared with younger adults, older widows and widowers are more likely to develop weaker functional disabilities and more chronic conditions, and to become sick and die (Hall & Irwin, 2001), as well as show grief for longer and experience poorer mental health outcomes (Supiano & Luptak, 2013). The majority of older people in widowhood experience major depression six months after the death of a partner (Hooyman & Kramer, 2006). Widowed elders have a greater chance of suffering and therefore are worthy of being given more attention. Among bereaved elders, a minority of them might experience a more difficult grief course for a longer time and poorer health outcomes than normally expected, or “complicated grief” (Shah & Meeks, 2012). The prevalence of complicated grief in older adults grieving over the loss of a spouse is also higher than that among younger adults (Ott, Lueger, Kelber, & Prigerson, 2007). Socially, older people have a high rate of decreasing their interaction with others in late life. According to disengagement theory (Cumming & Henry, 1961), older people gradually show less social interest and engage more in self-involvement consequent to their withdrawal from society. Based on these negative impacts on survivors physically, psychologically, and socially, the study gives much attention to travelling in the field with older people. This study focuses on elders aged 60 or over who have lost their loved partners as the target population.

1.2 Theoretical background

1.2.1 The classic theories of aging

Many efforts to investigate the late life course are evident. According to activity theory (Havighurst, 1963), life satisfaction in late life can be enhanced by active maintenance of personal relationships and participation in social activities. The loss of social roles due to age-related decline among elders can be replaced by newer engagements in active participation in social activities. In the context of bereavement, Gallagher and Gerstel (1993) found that widowed women engaged themselves more in interaction with friends compared to their married counterparts. According to continuity theory (Atchley, 1989), those older people who are most effective in maintaining the lifestyle developed earlier in life are those who handle loss most successfully (Utz, Carr, Nesse, & Wortman, 2002). Thus, in the face of age-related decline, it is wise to maintain the same social functions previously performed. Proponents of continuity theory emphasise both the perpetuation of activities and the prolongation of social roles that are of high importance and meaning to aging individuals (Cohen, 2014). It can be inferred that continuing to interact with others and participate in activities as before is beneficial for the widowed in adjusting to the death of their spouse.

Another theory of aging, namely socioemotional selection theory (Carstensen, Isaacowitz, & Charles, 1999), has advantages in comprehending the ongoing life course (Utz et al., 2002). This theory pertains to lifespan motivation. It suggests that social participation is the demonstration of strategic selections among elders aimed at improving social and emotional gains under the influence of perceived time. Elders tend to save resources for emotionally meaningful activities such as interaction with significant ones or from smaller social networks (Löckenhoff & Carstensen, 2004). They also prefer familiar social relationships across different cultures (Fredrickson & Carstensen, 1990; Fung, Lai, & Ng, 2001). Nevertheless, a spouse’s death appears to disrupt the structure of familiar social networks through which the elder achieves social and emotional gains. This kind of loss makes socioemotional selection theory useless in predicting emotional well-being among widowed elders (Pinquart & Sörensen, 2003).

In sum, although these theories of aging have advantages in explaining the process of aging to some extent, they are insufficient in explaining the specific life experience of bereaved elders. However, they are helpful for sustaining the examination of meaning making theory in this study of grief experience among Chinese elders living in rural areas.

1.2.2 Meaning making theory: understanding grief

Meaning making theory is preferable based on comparison with other theories related to grief, as well as evaluation criteria for selecting it. Grief is a research topic that has been studied for a long time. Freud’s psychoanalytic theory was the first major theoretical perspective on grief (Hooyman & Kramer, 2006), and was followed by other famous traditional grief theories, such as the stages theory (Kübler-Ross, 1970), the task theory (Worden, 1982), the six R’s process (Rando, 1993), and the attachment theory (Bowlby, 1980). In the theory of grief work, the bereaved person counts as normal if he or she lets go of the deceased and detaches themselves from their relationship with the dead. Psychoanalytic theory is limited for many reasons, such as the cultural issue and the detachment from the deceased. Obviously, grief is not a disease, but rather a normal experience. The sequence theories listed are not enough in explaining grief on their own since they neglect either the complexities of the social context or of the distinct patterns in which different individuals grieve (Thompson, 2012). Additionally, the mentioned traditional grief theories have been erroneous in the specific area of continuing bonds (Klass, Silverman, & Nickman, 1996). In fact, the bereaved cannot let go of the death completely; instead, they learn to move on with the deceased physically absent. People...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Acknowledgements
• 1. Background on grief
• 2. Grief and its diversity
• 3. Meaning making theory and traditional culture
• 4. Perspectives from meaning making model
• 5. Empirical feedback of bereaved Chinese elders based on meaning making model
• 6. Helplessness in bereaved Chinese elders
• 7. Conclusion and remarks
• References
• Appendix
• Index