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Resumé af Frida Ramsings speciale

Specialetitel: “When Death Becomes Complicated: A theoretical investigation and a Qualitative Study of Grief in Greenland” | Aarhus Universitet

Abstract

The thesis examines the theoretical foundations and phenomenological character of grief as it presents itself in Greenland. First, the thesis reviews the theoretical debate of grief as either: a potential pathology or fundamental feeling as it is represented by respectively health psychology and cultural psychology to research of Greenlandic psycho-sociological idiosyncrasies. The review indicates neither health- nor cultural psychology satisfyingly addresses how the idiosyncrasies influence grief. Secondly, the thesis accessed grief phenomenologically through a qualitative interview study of psychologists’ practical experiences. Data suggest that grief is a culturally specific phenomena, which is amplified in Greenland by the expression of living in a society with high levels of suicides and accidental death. The thesis takes into consideration that these rates will have an adverse influence on the expression of grief as a ubiquitous phenomenon. In conclusion, the findings of the thesis suggest that rather than constantly dealing with individual cases of grief with a universal pre-emptive approach to intervention, one should rather intervene on a societal level in Greenland.

Introduction

The scientific exploration of grief as a psychological phenomenon has in recent years gained momentum following the World Health Organization (WHO) enactment of a grief specific diagnosis in its 11th version of the diagnostic manual ICD (Guldin, 2019). The implementation of the diagnosis, named Prolonged Grief Disorder (PGD), is the result of decades of health psychology research. PGD is a loss-triggered disorder in which the grief reaction is considered long-lasting and associated with significant functional impairment. The reaction must go beyond what is expected in the cultural, social and religious context (WHO, 2019). 

Hence, the Greenlandic health sector shall now implement the functional use of PGD. However only one study has examined grief in Greenland. The study - conducted by Østergaard et al. (2020, p.19) - concludes that complicated grief reactions might be the “new normal” in Greenland. Complicated grief is an umbrella term for various grief triggered disorders such as PGD and depression (O'Connor, 2021), and so Østergaard et al. (2020) argue that many Greenlanders is of risk of developing PGD. I find this conclusion contradictory; if the normative grief reaction is complicated and therefore potentially pathological, how does a clinical psychologist then respond to the PGD criteria – that the grief reaction must go beyond what is expected in the cultural, social and religious context of Greenland? Østergaard et al.,(2020) conclusion provokes the need to investigate grief in a Greenlandic context in relation to how clinical psychologists understand grief, before we assume that grief should be thought of as a predominantly risk factor for developing psychopathology, including PGD. 

Another concern that can be raised, as we stand before the practical use of PGD in Greenland, is the criticism put forward from cultural psychologist of the diagnosis and health psychology in general. A central critic in the debate is Svend Brinkmann, who is a part of the grief project at Aalborg University (AAU) “Sorgens Kultur” (eng.: Grief Culture). Brinkmann, among others associates at AAU, is concerned that the use of PGD and the health psychology research in general undermines other central aspect of the grief experience, including existential and cultural aspects (Brinkmann & Kofod, 2017; Køster et al.,2018). I find it necessary to review this criticism and theoretical foundations of both cultural and health psychology to the Greenlandic context in which the diagnosis is to be used. 

The thesis research question is therefore: “How may one, based on psychological theory and practice, understand grief in a Greenlandic context?”, and the thesis answers this by a) reviewing theoretical contributions from health and cultural psychology ability to explain grief in Greenland, b) by assessing grief phenomenologically through a qualitative interview study of psychologists’ practical experiences, and c) by relating the psychological theories contributions to the reality of psychological practice in order to discuss, how we should understand grief in a Greenlandic contexts and these understandings implications moving forwards to implementing PGD.

The Review: The Greenlandic context and Grief Theory

The review of current psychological theories of grief and data on Greenlandic context is based on thorough literature search in databases such as PubMed, PsycINFO and AU library with various search combinations related to grief theory and Greenland. A chain search has been conducted in the located material. Furthermore, searches have been conducted on major Greenlandic and Danish media websites, e.g. DR and KNR, for articles on current Greenlandic conditions.

Grief in Greenland: A matter of specific idiosyncrasies creating complicated deaths

To understand the importance of studying grief in a Greenlandic context, one must first turn to the cause of grief – death. Greenland has one of the world’s highest suicide rates (Pedersen & Kristensen, 2021a). Researchers Bjerregaard and Larsen (2015) describe how suicide in the pre-colonial Inuit communities used to be an altruistic act, but it is now an individual act of tragedy. A tragedy constituted by Greenlandic society’s challenges e.g. sexual abuse, incest, alcohol culture and violence (Bjerregaard & Larsen, 2015). These challenges are widespread to such an extent that it is possible to consider them greenlandic psycho-sociological idiosyncrasies, i.e. life conditions special to greenlandic culture, history and social living conditions (Bolliger & Gollis, 2018). Idiosyncrasies that, according to researchers, can be linked to Greenland’s status as a former Danish colony and the continued connection to Denmark (Bolliger & Gollis, 2018; Bjerregaard & Larsen, 2015; Zaragoza Scherman, 2017; Bjerregaard & Lynge, 2006; Gregersen, 2010). There is thus reason to believe that particularly the rapid and life-changing social changes in the post-war period and onwards caused an alienation from the Inuit culture and an internalized inferiority towards the colonial power. This alienation seems to have had a number of psycho-social consequences, most clearly reflected in the presence of psycho-sociological idiosyncrasies such as sexual abuse, violence and alcohol problems which create fertile ground for the maintenance of the high suicide rates established in the post-war period.

For the common Greenlander contact with the psycho-sociological idiosyncrasies, either on their own body or as a witness, thus seems inevitable. About 60% of the adult population and 69% of the 18 to 24-year-olds have lost friends or family to suicide (Østergaard et al., 2020). In addition, 18.6% of all causes of death were so-called unnatural – or complicated, if you will – as a result of murder, accidents and suicide in the period 2000-2013. In the same period, it was about 4.5% in Denmark (Østergaard et al., 2020). So where does complicated death leave the bereaved?

As mentioned above, only Østergaard and colleagues (2020) have examined grief in Greenland. The authors conclude that grief in a Greenlandic context should be considered as being both constituted and reinforced by mentioned psycho-sociological idiosyncrasies. Hence one cannot fully understand grief in a greenlandic context without including these idiosyncrasies (Østergaard et al., 2020). However, according to Østergaard et al. (2020) grief is often downplayed by professionals in favor of dealing with other psycho-social challenges. The authors’ hypothesis is that many Greenlanders are of risk of PGD and other grief related reactions as idiosyncrasies, especially bereavement after suicide, are risk factors for development of PGD.

Theories of Grief: A phenomena for debate

Grief is a well-established research area within psychology in general, in which cultural and health psychology constitutes two significant and divergent positions (Larsen et al., 2018; Brinkmann & Kofod, 2017). 

Health psychology represents psychological researchers who view grief as a process which can have either a natural or a complicated course, the latter of which can develop into PGD (Larsen et al., 2018). PGD is considered a tool to accommodate the suffering of a clinical subgroup of mourners, who are suffering from a long-lasting grief with significant functional impairment (Prigerson et al., 2021). PGD is associated with risk of suicidal thoughts, reduced quality of life and the development of other psychical disorders (Larsen et al., 2018; Crunk et al., 2017). The wish is to help distressed individuals, who do not profit from other forms of treatment e.g. depression therapy. Thus, health psychologists welcome the new diagnosis as it will guide the way for grief-specific treatment (Prigerson et al., 2021; O’Connor, 2021).

Cultural psychologist focus on grief has primarily arisen as a reaction to the prospect of PGD being implemented in ICD-11 (Guldin, 2019). Cultural psychologists find that the framing of grief as a potential pathology undermines other important aspects of the concept including normative and cultural dimensions (Brinkmann, 2018c). In cultural psychologist Brinkmann’s (2018c) view, one should withdraw from pathologizing grief. Thus, Brinkmann argues that grief should be considered a fundamental emotion rather than a potential pathology (Brinkmann,2018b). Grief is fundamental because the emotion of it illuminates something essential about being human, as grief is the price we pay for love (Brinkmann, 2018b). Brinkmann (2018b) argues that as the reality of death is universal thus, the fundamental feeling of grief that accompanies it is an existential basic condition across cultures. It is worth noticing, as grief is a generic basic condition, it is therefore also a basic human condition, and therefore Brinkmann (2018a) argues against the potential pathologization of grief the implementation of PGD in ICD-11 symbolizes.

When theories of Grief meet the Greenlandic reality

Cultural and health psychological theorization of grief will now be assessed in relation to the above presented data on Greenlandic psycho-sociological idiosyncrasies.
From a health psychology perspective, one would assume that a typical case of loss in Greenland often could be considered a potential risk factor for developing PGD, as many of the present psycho-sociological idiosyncrasies such a high suicide rates constitutes risk factors. This is in line with the arguments put forward by Østergaard et al, (2020) based on the authors study of grief in Greenland. But based on our current knowledge, can one really assume that the normative grief reaction in Greenland should be equated with pathological grief (i.e. PGD)? It seems hasty to conclude this, when the empirical basis for PGD criterion; that the pathological grief response must extend beyond the person’s cultural, religious and social context, is still very limited (O’Connor, 2021). 

Cultural psychology’s concept of grief – as represented by Brinkmann’s (2018c) theory “grief as a fundamental emotion” – also seems to be fraught with challenges, when compared to data from the Greenlandic context. Brinkmann (2018c) wishes to capture something generic about grief as a phenomenon across cultures, but does the concept of grief “as the price of love” run true in Greenland? Considering that 18.6 % of all deaths are caused by accidents, suicides and murders in Greenland (Østergaard et al., 2020), one could instead argue that grief should be considered the price of living in a context where one is often exposed to this type of death. Brinkmann (2018b) criticizes health psychology for undermining cultural aspects of grief. However, one could argue, that the authors generic concept of grief also undermines culturally and context specific dimensions such as exposure to suicide. 

Hence, neither health psychology nor cultural psychology seems to succeed in adequately including psycho-sociological idiosyncrasies in the theorizing of grief, which makes their theories difficult to apply to a Greenlandic context. Therefore, we must turn from theory to practice. 

The study: Psychologist practically experiences with Grief in Greenland 

The thesis accessed grief phenomenologically through a qualitative interview study of psychologists to answer the research question: How may one, based on psychological practice, understand grief in a Greenlandic context?

Method and analysis

The research question is assessed by qualitative methodology because it seeks to capture culture specific nuances of grief, which cannot be elucidated in the same way by quantitative methods (Køster et al., 2018; Kvale & Brinkmann, 2015). Hence, I conducted a qualitative semi-structured interview that explored the experiences of Greenlandic and Danish psychologists working in Greenland. The psychologists’ experiences are a valuable source of information about how grief is expressed specifically in Greenland, as they themselves are a part of Greenlandic context, and therefore engaged in its norms, history and culture.

In total, five psychologists participated, and they were interviewed in the fall of 2021 either online or at Aarhus University. The psychologists were both greenlandic and danish. The psychologists worked or had previously been practicing in the cities and settlements in south and west Greenland. The interviews were recorded, transcribed and treated in accordance with Aarhus University’s guidelines for processing of personal data (AU, 2022). A thematic analysis of the interviews was subsequently conducted using Braun and Clarke’s (2006) thematic analysis. Thematic analysis identifies patterns across the data constituted by a series of codes. On the basis of this identification, it is then possible to interpret the themes in relation to the research question (Braun & Clarke, 2006).

Results

Through thematic analysis 3 themes were located.
The first theme, named “Collectivistic Grief”, indicates that grief is an experience rooted in the collectivistic practices of Greenland. Greenlandic culture is described as collectivistic, hence deaths and the following traditions are dealt and done together in the community rather than in privately. The analysis indicates that the collectivistic culture increases the exposure to death, including suicide and accidents, and therefore the individual is often confronted with grief – both the personal grief as well as grief expressed by other members of the community. Some of the psychologists expressed concerns that the collectivistic practices might make it difficult for some individuals to overcome the personal grief especially if it is due to violent loss, as you so often will be reminded of these types of deaths in your community.

The second theme “Grief as one of several harsh psycho-sociological idiosyncrasies” frames grief as omnipresent due to the aforementioned exposure to death in the collectivistic communities. Therefore, grief is described to be a general psycho-sociological idiosyncrasy in Greenlandic culture. When the cause of death is complicated, such as suicide or accident, grief seems to be fraught with suffering, anger and meaninglessness. Grief is described as an expression of Greenland’s problems with suicide and accidents, and that the processing of grief is compressed by the exposure to the other psycho-sociological idiosyncrasies, such as sexually abuse, violence, neglect and alcohol abuse. Grief is then considered not only a fundamental feeling that is “the price of love”, as cultural psychologist Brinkmann (2018a) argues, but as the exposure to these idiosyncrasies. 

The third and final theme “Psychological Practice” illuminates how the interviewed participants’   understanding of pathology and psychological intervention are connected to the psychologist’s culturally sensitive understanding of grief as both culturally rooted and as a phenomenon in interaction with the present  psycho-sociological idiosyncrasies. The psychologists dismiss PGD relevance in a Greenlandic context. They argue that grief instead should be regarded as a general phenomenon in a landscape of harsh psycho-sociological idiosyncrasies. The psychologists argue that these idiosyncrasies require intervention both on an individual and collective level.

Discussion: How to move forward in Greenlandic psychological practice with Grief?

My data suggest that grief is a culturally specific phenomena, and this is amplified in Greenland by the expression of living in a society with high levels of suicides and accidental death as well as other harsh psycho sociological idiosyncrasies. The thesis takes into consideration that especially the suicides rates will have an adverse influence on the expression of grief as a ubiquitous phenomenon. In my study I found that culturally specific psycho-sociological idiosyncrasies affect not only the expression of the psychological phenomena grief, but also the psychological practices regarding it. In this light it is problematic that prominent grief-theories presented by health and culture psychology do not account for how cultural variation of grief influences as we saw established in my review and my data. Hence the need for discussions on how we should understand grief in a Greenlandic context properly and the implications this understanding will have moving forward.

The findings of the study suggest that rather than constantly dealing with individual cases of grief with a universal pre-emptive approach to intervention, one should rather intervene on a societal level. When we access grief with sensitivity for its cultural specificity, it is clear that the phenomenon’s ubiquitous character is a witness to the exposure to suicides and accidental deaths via the collectivistic societal structure in Greenland. In this light the ubiquitous character of grief should not be considered a risk factor for the development of mental disorder, and therefore Østergaard et al. (2020) interpretation that many Greenlanders should be at risk of developing PGD seems simplistic. However, the psycho-sociological idiosyncrasies undoubtedly cause great suffering, and my study indicates that individual treatment is needed until the necessary societal changes have been made. But, since the causes of the suffering are rooted outside the individual, interventions on an individual level will never reach the heart of the matter.
The concern is therefore that usage of PGD in a Greenlandic context will cause an illegitimate pathologization of what is a natural reaction to harsh psycho-sociological idiosyncrasies. Young Greenlanders predominantly commit suicide due to a personal or social crisis, and not due to a mental disorder (Bolliger and Gollis, 2018). This indicates that the problems must be found outside the individual in order to intervene efficiently. 

The thesis results are limited due to practical limitations. It would have been the obvious choice to interview Greenlanders about the cultural specifics of grief. Although my Danish participants are concerned with approaching phenomena culturally sensitively, they will never be able to fully describe the culture from within, and thus they become a second-hand source. Therefore, the primary limitation of my study is in line with the general research trend in Greenland, where studies often do not include qualitative data from the Greenlandic population, but predominantly deal with expert interviews or quantitative data (e.g. Østergaard et al., 2020; Bolliger & Gollis, 2018; Bjerregaard & Larsen, 2015).

Another limitation of the thesis is my lack of cultural sensitivity as I have not interviewed participants who work in East Greenland only in Western and southern Greenland. Although the Greenlandic people are a small population, there are cultural differences between East Greenland and the rest of the country (Bjerregaard & Curtis, 2002). East Greenland was later colonized and modernized than the other areas of the country, which let the social changes to be experienced much more overwhelming in this part of the country, which also has the highest murder and suicide rate (Bjerregaard & Curtis, 2002; Bjerregaard & Larsen, 2015). In this light my findings of how much the psycho-sociological idiosyncrasies influence grief in Greenland could be considered to be conservative.

Conclusions

The thesis consisted of a theoretic exploration and qualitative study of psychological practice with the aim of answering the problem formulation: How can one, based on psychological theory and practice, understand grief in a Greenlandic context? The thesis illustrates that the presented psychological grief theories from two central currents, health psychology and cultural psychology, do not take into account that the expression of grief will be affected by specific factors in the given society. In the past, Inuits committed suicide as an altruistic act for the sake of the community. But today suicide is a cumulation of the individual's catastrophe in a country where psycho- sociological idiosyncrasies such as exposure to suicide cause grief to be ubiquitous. To meet this knowledge gap that arises in light of the psychological theories’ shortcomings, the thesis assesses psychological practice through a qualitative study in order to understand how grief is particularly expressed in the Greenlandic context in relation to the psycho-sociological idiosyncrasies. This was investigated via semi-structured interviews with psychologists working in Greenland, in order to anchor the study of grief in the Greenlandic context. I found that, based on psychological practice, grief in Greenland can be understood as a reaction to psycho-sociological factors in the context, and intervention aimed at society's challenges is necessary to meet the grief of the individual Greenlander.

Reflection – on the relevance of the thesis for Greenlandic-Danish relations

The thesis primary attribution to the Greenlandic-Danish relations is that it highlights cross-cultural challenges in psychological practices within the Rigsfællesskab, and the need to recognize these differences in our psychological practice, when we together have to solve psychosocial challenges.

Of the 50-55 psychologists working in Greenland around 35 speak Greenlandic (Østergaard et al, 2020), hence many psychologist positions are filled by Danes with varying knowledge of Greenlandic culture. It is not yet possible to study psychology at the University of Greenland, Ilisimatusarfik, and the education of Greenlandic psychologists at Danish universities is based on western literature, theory and data – and in my experience – a very limited introduction to the psycho-social conditions and culture of Greenland. In addition, psychologist positions in Greenland are often filled by Danes who are in the country for a shorter time and therefore do not necessarily have sufficient knowledge of the culture. This constitutes a challenge in the light of my thesis results; that psychological phenomena such as the expressions of grief are culturally specific. The thesis therefore contributes by illuminating the need for scientific studies of cross-cultural differences within the Rigsfællesskab, if we want to solve the mental health challenges so prominent in Greenland.

The thesis not only underlines the need for psychological cross-cultural studies within Rigsfællesskabet, as it also sheds light on current cross-cultural challenges psychologists in Greenland face on a daily basis through its empirical qualitative study. The thesis concludes that a central aim in psychology practice should be cultural sensitivity. Thus, the psychologist must be aware that phenomena such as grief are necessary to review in the context of the individual’s systemic, cultural and historical origin. However, this makes great demands for the individual psychologist's introduction to Greenlandic culture, including awareness of how their own cultural background plays a role. As Brooker (2018) points out, based on her own experiences and empirical evidence from interventions in Inuit communities in Canada, it is a major challenge that professionals in the health sectors are alienated from the history of Inuit culture. It can be said that the professionals thereby unintentionally mirror the alienation that the Inuit themselves struggle with. However, there seems to be hope, as the interviews conducted in my study indicates that the psychologist – both Greenlandic and Danish- already are aware of this challenge. It comes to light as the interviewed participants are aware that psychopathology and grief are dependent on the cultural context, hence they are reluctant to use PGD in psychological practise as they find it not insufficient to target the true problem – the psycho-sociological idiosyncrasies, that makes grief ominous. 

Hopefully the thesis insights can contribute highlighting the need for research that investigate how psychological phenomena vary across Rigsfællesskabet and how best to intervene, so that everyone has access to psychological interventions that addresses precisely the challenge that the individual Greenlander, Faroese or Dane faces in light of the cultural specific psycho-sociological idiosyncrasies.

Specialet er indstillet til specialekonkurrencen 2022.

Senest opdateret 16. november 2022