Disaster-related bereavement: A study of long-term mental health effects and interventions Pål Kristensen Norwegian Centre for Violence and Traumatic Stress Studies Thesis submitted for the Degree of Dr. philos., Faculty of Medicine, University of Oslo, 2012 © Pål Kristensen, 2012 Series of dissertations submitted to the Faculty of Medicine, University of Oslo No. 1371 ISBN 978-82-8264-362-7 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Inger Sandved Anfinsen. Printed in Norway: AIT Oslo AS. Produced in co-operation with Unipub. The thesis is produced by Unipub merely in connection with the thesis defence. Kindly direct all inquiries regarding the thesis to the copyright holder or the unit which grants the doctorate. CONTENTS Acknowledgments .................................................................................................................. 1 List of papers .......................................................................................................................... 3 Abbreviations ......................................................................................................................... 4 1. INTRODUCTION ................................................................................................................ 5 1.1 Bereavement, grief, and mourning ................................................................................... 5 1.2 Why conduct research on bereavement and disasters? .................................................... 5 1.3 A personal account ........................................................................................................... 7 2. BACKGROUND ................................................................................................................... 9 2.1 A brief history of the scientific study of grief and bereavement ...................................... 9 2.2 Disaster and bereavement research in Norway .............................................................. 10 2.3 Loss after sudden and violent death ............................................................................... 11 2.4 Loss of a child ................................................................................................................ 13 2.5 When grief becomes a disorder ...................................................................................... 13 2.5.1 A brief review of the concept pathological grief ..................................................... 13 2.5.2 Complicated grief (CG) or prolonged grief disorder (PGD) - proposal for a new disorder ..................................................................................... 15 2.5.3 Risk factors for PGD ............................................................................................... 18 2.5.4 Treatment of PGD ................................................................................................... 18 2.5.5 The debate and controversy of a grief disorder ....................................................... 19 2.5.6 Current suggestion for DSM-5 ................................................................................ 19 2.6 Research on disaster-related bereavement ..................................................................... 22 2.6.1 Challenges and dilemmas ........................................................................................ 22 2.6.2 Mental health effects ............................................................................................... 22 2.6.3 Long-term impact .................................................................................................... 24 2.6.4 Interventions ............................................................................................................ 24 2.7 The disasters ................................................................................................................... 25 2.7.1 The 2004 South-east Asian tsunami ........................................................................ 25 2.7.2 The 1986 Vassdalen avalanche ............................................................................... 27 3. AIM OF THE THESIS ...................................................................................................... 28 3.1 The Tsunami bereavement study .................................................................................... 28 3.2 The Vassdalen avalanche study ...................................................................................... 28 3.3 Ethical aspects ................................................................................................................ 28 4. METHODS ......................................................................................................................... 29 4.1 Design and procedure ..................................................................................................... 29 4.2 Participants ..................................................................................................................... 30 4.3 Measures ......................................................................................................................... 31 4.4 Psychometric assessments .............................................................................................. 31 4.5 Statistical analyses .......................................................................................................... 35 5. SUMMARY OF RESULTS ............................................................................................... 37 5.1 Main findings from paper I ............................................................................................ 37 5.2 Main findings from paper II ........................................................................................... 38 5.3 Main findings from paper III .......................................................................................... 39 5.4 Main findings from paper IV ......................................................................................... 40 5.5 Main findings from paper V ........................................................................................... 41 6. GENERAL DISCUSSION ................................................................................................. 42 6.1 Methodological considerations ...................................................................................... 42 6.2 The level of grief and mental disorders .......................................................................... 43 6.3 Risk and protective factors ............................................................................................. 45 6.4 The trajectory of grief .................................................................................................... 46 6.5 Support for a grief disorder? .......................................................................................... 47 6.6 The significance of interpersonal factors in grief ........................................................... 47 6.7 Early interventions after disasters - visiting the site of death ........................................ 48 6.8 Implications .................................................................................................................... 49 6.8.1 Implications for clinicians ....................................................................................... 49 6.8.2 Implications for future research .............................................................................. 51 6.9 General conclusions ....................................................................................................... 51 REFERENCE LIST ............................................................................................................... 53 PAPERS I-V ............................................................................................................................ 69 Acknowledgments This study was carried out at the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) in Oslo from 2006-2010. I thank all the staff at the centre for their encouragement and support through these years. I also would like to thank both the Ministry of Health and the Ministry of Defence for financing the study. Many persons have in different ways contributed in making this thesis possible. My sincere gratitude goes to the following: Professor and supervisor Lars Weisæth for his confidence in me when he recruited me for this study, for his wisdom, encouragement, patience, and friendliness which have been so valuable for me through the work with this thesis. Senior researcher and supervisor Trond Heir for contributing with his rich academic skills, ability to see solutions, his encouragement, patience, and continuous support which have been of immense help. Other colleagues, especially Ajmal Hussain and Anne Lie Andreassen for assisting with the interviews, Siri Thoresen and Egil Nygaard for useful discussions, and Arnfinn Tønnessen, Pål H. Herlofsen, and statistician Øyvind Langsrud for their important contributions on two of the articles in the thesis. Bærum Kommune for giving me the opportunity to engage in this study. My interest in the field of grief and bereavement really started in 2000 when I began working as a clinical psychologist at Senter for Sorg og Selvhjelp in Bærum. I had some very exciting years there with very skilled colleagues. I would like