development and validation of a christian-based grief recovery scale
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This article was downloaded by: [Lahore University of Management Sciences]On: 18 November 2014, At: 19:51Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
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Development and validation of aChristian-based Grief Recovery ScalePeter Jen Der Pana, Liang-Yu F. Denga, S.L. Tsaia, Ho-Yuan J. Chena
& Sheng-Shiou Jenny Yuanb
a College of Humanities and Education, Chung Yuan ChristianUniversity, Taiwanb Student Counseling Center, Kainan University, TaiwanPublished online: 13 Nov 2013.
To cite this article: Peter Jen Der Pan, Liang-Yu F. Deng, S.L. Tsai, Ho-Yuan J. Chen & Sheng-ShiouJenny Yuan (2014) Development and validation of a Christian-based Grief Recovery Scale, BritishJournal of Guidance & Counselling, 42:1, 99-114, DOI: 10.1080/03069885.2013.852158
To link to this article: http://dx.doi.org/10.1080/03069885.2013.852158
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Development and validation of a Christian-based Grief Recovery Scale
Peter Jen Der Pana*, Liang-Yu F. Denga, S.L. Tsaia, Ho-Yuan J. Chena andSheng-Shiou Jenny Yuanb
aCollege of Humanities and Education, Chung Yuan Christian University, Taiwan; bStudentCounseling Center, Kainan University, Taiwan
(Received 11 November 2012; accepted 25 September 2013)
The purpose of this study was to develop and validate a Christian-based GriefRecovery Scale (CGRS) which was used to measure Christians recovering fromgrief after a significant loss. Taiwanese Christian participants were recruitedfrom churches and a comprehensive university in northern Taiwan. They wereaffected by both the Christian faith and Chinese cultural beliefs. The CGRS isdeveloped through replicated factor analyses in three stages. The final version ofthe CGRS retains 35 Likert-type items and consists of six factors: spiritual well-being; recovering meaning and sense of control; ongoing physical and emotionalresponses; reassuring faith; strongly missing a deceased loved one; and lifedisturbance. The evidence for CGRS reliability and validity is highlighted.Implications for research and counselling practice are suggested.
Keywords: Christian; culture; grief; Kübler-Ross theory; spirituality
Introduction
Death and bereavement in Chinese cultures
Death remains a fearful, frightening incident and the fear of death is universal, even in amodern, scientifically advanced society (Charles-Edwards, 2005). Discussing death isculturally forbidden for Chinese people (Hsu, Kahn, Yee, & Lee, 2004). In the spring,particularly during the Chinese Lunar New Year, mentioning death is strictly prohibited.In the summer, the best way to feel comfortable in the ‘ghost month’ of July in theChinese Lunar calendar is to avoid mentioning death. In the autumn, the moon festival istraditionally to bless and to get family members together without mentioning death. In thewinter, a time when people are more susceptible to disease, the topic of death and lossshould not be discussed. Obviously, open and public discussions of death, particularlyamong Taiwanese people who are affected by Chinese culture, remain one of the greatestsocietal taboos (Ho, 2007; Lee, 2002). In this context, little is known regarding howpeople grieve and recover from loss. Death, loss, grief and bereavement have becomemysterious, complicated and even unpredictable for people in the Chinese culture.
In fact, grief is a normal, healthy, spontaneous, natural, unlearned, emotional healingprocess that occurs following a significant loss (Kübler-Ross, 1969, 2005). Grief is
*Corresponding author. Email: [email protected]
British Journal of Guidance & Counselling, 2014Vol. 42, No. 1, 99–114, http://dx.doi.org/10.1080/03069885.2013.852158
© 2013 Taylor & Francis
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experienced through emotional thinking, physical, social and spiritual/religious responsesthat come and go in reaction to loss. Grief reactions may occur not only after a death butalso after significant life changes or transitions, such as the loss of a pet, job or marriage,or on retirement (Kübler-Ross, 1969, 2005). Thus, grief is experienced uniquely by eachperson and is shown in various forms in each culture.
Using in-depth interviews, Ho (2007) explored the bereavement experiences ofChinese parents who had encountered the death of a child. Ho found that the way theyconnected with the deceased child and their worldviews were influenced by culturalbeliefs and values. Ho (2007) postulated that the use of object linking, memorialising actsand avoidance of traditional funeral processes were frequently employed for parentalconnections with the deceased child. Furthermore, the use of the concept of fate as arationale for child loss is one of the main themes. Finally, Ho concluded that the influenceof cultural beliefs and background on Chinese parents as they dealt with a child’s deathwas apparent (Ho, 2007).
Hsu et al. (2004) further inspected Taiwanese cultural patterns as they affectadaptation to loss in the form of death. They suggested that reconnection is a culturallyspecific and accepted means of resolving grief among Taiwanese. Hsu et al. (2004)identified that the Taiwanese concept of reconnection entails (a) maintaining the statusquo, (b) restoring images of the deceased in family affairs and (c) communicating withthe dead. Each theme represents the efforts of the bereaved families to retain a sense ofwholeness (a central Chinese goal) and to preserve symbolic images of fathers andhusbands (Hsu et al., 2004).
In a qualitative study using three focus groups, Yick and Gupta (2002) examinedChinese immigrants’ and Chinese Americans’ attitudes and practices concerning death,dying and bereavement. They found that Chinese attitudes and practices in these areas arerooted in Asian cultural values such as filial piety, centrality of the family and emphasisof hierarchy. Inevitably, strains of Confucianism, Buddhism, Taoism and local folkloreare embedded in these attitudes and practices (Yick & Gupta, 2002).
Death and bereavement in Christianity
For most Christians, the issue of death and bereavement provides the sharpest challenge toour trust in God. If faith can overcome this, there is a buffer between death andbereavement (Chang, 2005). The fact is that if you truly love someone, you grieve whenthey leave life and leave you behind. It is love that makes death bearable, because genuinelove is not diminished under any circumstances, even after death. Christians believe that itis the love of Jesus that holds these two opposites together. Through Jesus, Christians holdthe hope that death is not the end (Charles-Edwards, 2005). The Christian hope is that faithin God can help people to free themselves from being permanently in slavery to the lossthey have suffered (Chang, 2005). It allows people to readjust to the world without thedeceased person, and to create a context in which new friendships can be formed.
From a Christian perspective, Charles-Edwards (2005) postulated that Christianstraditionally believe in life after death, although some of them are unsure. Heaven andhell were originally ideas from a pre-scientific concept of a three-tier universe. Moreover,Christian texts describe heaven as a garden-like paradise where the spirits of the blessedor righteous go after death. It is the abode of God and the angels and is permeated by thedivine spirit. These concepts powerfully impact Christians in their response to death andgrief (Chang, 2005). Suffering from death and bereavement is an unavoidable issue inChristianity.
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In fact, Marrone (1997) examined the cognitive basis of the spiritual experience andthe use of cognitive assimilation, as well as the accommodative strategies during theprocess of mourning the death of a loved one. The specific ways in which peoplerediscover meaning, such as belief in traditional religious doctrine, the afterlife,reincarnation, philanthropy or a spiritual order to the universe, may be less importantthan the process itself (Marrone, 1997). Finally, Marrone (1997) concluded that in theprocess of dealing with profound loss in our lives, the ability to reascribe meaning to achanged world through spiritual transformation, religious conversion or existentialchange may be more significant than the specific content by which that need is filled.
The similarities and differences between these two systems of belief
Cross-cultural issues exist everywhere because culture affects who we are, how we think,how we behave and how we respond to our environment. Hence, all societies have theirown customs and beliefs surrounding death. In the West, although science has had amajor impact on views of death, it has taught us little about ways in which to die or togrieve (Parkes, Laungani, & Young, 1997, p. 157). Death and bereavement issues acrossWestern cultures are handled by providing a handbook with which to meet the needs ofdoctors, nurses, social workers, counsellors and others involved in the care of the dyingand bereaved. In the East, however, it is characterised by an authoritarian, collectivisticand hierarchical structure in nature, which serves to guide people’s behaviours,relationships and connections with nature. In a traditional Chinese family, the closerelationships among family members or significant others fully provide support to thosewho are suffering from loss (Fang & Nieh, 2006; Hsu et al., 2004).
Both Eastern and Western religions teach people that life is a time of trial and testing,and an individual’s actions in life affect his or her next destination. In Eastern cultures,Buddhism teaches people that a person’s ability to be reincarnated after death as ananimal or another human being depends on one’s deeds in the previous incarnation(Parkes et al., 1997, p. 151). The cycle continues until the individual finds identity andunity with the cosmos. In other words, each person has a succession of lives, and to bereborn or reincarnated into other forms of life is determined by the person’s character andactions during the previous lifetime. Christians, on the other hand, hold the view that thesoul may go to heaven, hell or some intermediate place, depending on whether or not oneattains salvation and God’s grace (Charles-Edwards, 2005).
In a cross-cultural study, Bonanno, Papa, Lalande, Zhang, and Noll (2005) measured griefprocessing and deliberate grief avoidance in the People’s Republic of China and the UnitedStates. Based on their findings, cultural differences in grief processing and avoidance do exist.Consistent with the grief work as rumination hypothesis, both grief processing and deliberategrief avoidance predicted poor long-term adjustment for US participants. Furthermore, initialgrief processing predicted later grief processing in both cultures. However, among theparticipants in the People’s Republic of China, neither grief processing nor deliberate griefavoidance evidenced clear psychological consequences (Bonanno et al., 2005).
Psychological models of death and bereavement
Based on her research and interviews with more than 500 dying patients, Kübler-Rossdescribes a five-stage model, including denial, anger, bargaining, depression andacceptance, as a part of the framework that makes up our learning to live without theone we love (Kübler-Ross, 1969, 2005). There are specific types of responses, reactions
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and adjustments to go through in each stage. According to Kübler-Ross’s theory, thesestages do not necessarily come in order, nor are all stages experienced by all patients(Kübler-Ross, 1969, 2005). Often, people will go ‘back and forth’ between two or morestages, returning to one or more several times before working through it. In fact, thetheory says that the reactions to illness, death and loss are as unique as the personexperiencing them. Some people may get stuck in one stage. Kübler-Ross originallyapplied these stages to people suffering from terminal illness. She later expanded the useof this theoretical model to include any form of catastrophic personal loss. Such lossesmay also include significant life events such as the death of a loved one, major rejection,the end of a relationship, divorce, drug addiction, incarceration, a change in officeenvironment, the onset of a disease or chronic illness, an infertility diagnosis as well asmany other tragedies and disasters (Kübler-Ross, 2005).
Grief is a natural response to any loss. Although the Kübler-Ross model is useful toidentify and understand how people are dealing with change, the critical argument isrelated to the simplicity of the five stages which do not adequately describe the widerange of emotions people experience during change. The model is also criticised formaking assumptions about its broad applicability. In fact, it is unlikely that people fromall over the world with a variety of cultures experience the same reactions and emotions.In addition, there are limitations in the research method, because only personal interviewswere used. The interviews should have been followed by different forms of datagathering. Finally, Kübler-Ross did not take the personal environment into consideration.If patients were surrounded by a positive environment, they would experience thingsdifferently than if they were surrounded by a negative environment (Fang & Nieh, 2006).Bonanno (2004) even suggested that the Kübler-Ross stages of grief do not exist.Bonanno indicated that most people who experience a loss do not grieve, but are resilient.If there is no grief, there can be no stages of grief. He concluded that a natural resilienceis the main component of grief and trauma reactions. The logic is that if there is no grief,there are no stages to work through.
Although grief is highly individualised, a consensus is made that grief is a dynamicprocess and time and effort are needed to get through it (Cowles, 1996; Cowles &Rodgers, 1991). Recovering from grief and loss depends on personal past experience(Worden, 1991), cultural background (Cowles, 1996), a supportive system and therelationship with the lost one (Fang & Nieh, 2006). The grief reaction is pervasive,including emotional, physical, social, cognitive and spiritual responses (Cowles &Rodgers, 1991; Fang & Nieh, 2006). Although the process of grief is multifaceted,Worden (1991) aggregated the vast repertoire of normal grief reactions under four generalcategories: emotional response, physical sensations, altered cognitions and behaviours.
Mourning is synonymous with grief over the loss of a loved one. However,bereavement is a period of mourning after a loss, especially after the death of a lovedone. In some cases, the normal process of mourning becomes an abnormal one, which isreferred to as the ‘complicated bereavement’ (Worden, 1991). The complicatedbereavement or traumatic grief is the intensification of grief to a level such that theperson feels overwhelmed, resorts to maladaptive behaviour or remains interminably in astate of grief without progression towards completion of the mourning process (Worden,1991). Although the process of coping with loss is different for everyone, evidencesuggests that grief can prompt personal growth as well as despair, augmenting rather thansimply reducing the survivor’s sense of meaning (Neimeyer, Prigerson, & Davies, 2002).
Normal and complicated mourning are on a continuum, with extremes of effect,intensity and time scale determining pathology, rather than the presence of any one
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particular symptom (Worden, 1991). The normal process of mourning can turn intocomplicated mourning for a number of reasons, which include: (1) difficult circumstancessurrounding the death, such as multiple losses within a short time period; (2) a person’shistory of grieving experiences; (3) the personality of the bereaved person; and (4) socialfactors surrounding the death, such as how the person died and the availability of socialsupport (Worden, 1991).
Previous literature on recovering from grief has focused on conforming to a series oftasks: to accept the reality of the loss, to work through the pain of grief, to adjust to anenvironment in which the deceased is missing and to emotionally relocate the deceasedand move on with life (Fang & Nieh, 2006; Worden, 1991). However, more recenttheories suggest that the resolution of grief involves continuing bonds, where thesurvivors maintain a relationship with the deceased, and that these continuing bonds canbe a healthy part of the survivor’s ongoing life (Worden, 1991). Bowlby (1980) furtheridentified the role of attachment as a key factor to relocate the relationship between thedeceased and the survivor. Lee (2002) postulated nine steps to recover from grief,including accepting the reality of loss, experiencing courage and patience through theexpression of painful feelings, finding meaning in life, searching for a new meaningfulway to connect with the deceased, working through one’s defences, establishing a healthysupportive system and relationship, understanding more about self-strengths and thepower to maintain a positive image and sense of control, rebuilding psychological andphysical health, managing life priorities and developing a new attitude to deal with thefear of death and family conflicts.
Research has indicated that bereaved persons who were helped by religion andspirituality-related variables dealt with depression more effectively than those who werenot spiritually oriented (Tan, 2007). Religious coping has been utilised effectively toaddress a variety of painful life situations, including stress, illness, victimisation and theloss of a loved one (Tan, 2007). Such positive coping consists of seeking spiritualsupport, collaborative religious coping, spiritual connection and benevolent religiousreappraisal (Pargament, Smith, Koenig, & Perez, 1998). Recent research shows thatpastoral counselling incorporating spiritual resources such as Scripture and prayer is oftherapeutic benefit and can contribute to a believer’s quality of life and to theirperceptions of well-being (Gubi, 2004; Maltby, Lewis, & Day, 1999; Pargament et al.,1998; Tan, 2007). Tagliaferre and Harbaugh (1990) found that the process of grief isdifferent for everyone because those differences are manifested in actions and thoughtsthrough the physical, emotional, intellectual, and spiritual aspects of loss. If griefresponses are correlated with spiritual variables, then it is possible that recovering fromgrief is also related to such variables.
For Christians, death is a time for grieving and celebrating the person’s life.Nevertheless, a danger for some Christians is to be so sure of the joy of being with Godafter death that to avoid being criticised as showing a lack of faith, grieving can beundermined (Charles-Edwards, 2005, p. 141). This may potentially threaten somebeginner or novice Christians. Therefore, to develop an instrument to measure the degreeof grief recovery from the perspectives of Christian faith may be helpful to betterunderstand the effective recovery factors. First, it allows researchers to examineChristians’ recovery processes empirically and practically. Second, it responds to thecall by clinical pastoral counsellors to develop valid instruments to measure Christians’recovery levels from grief. Third, this instrument will facilitate empirical studies ofspiritual interventions with Christian clients. Finally, a comparison of the demographicvariables on the issue of grief recovery is accessible in future cross-cultural research.
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Based on the literature review, the purpose of this study was to develop and validate aChristian-based Grief Recovery Scale (CGRS) which was used to measure Christianparticipants’ recovery from grief after a significant loss.
Methods
Taiwanese Christian participants are embedded in a Confucian society and hold Christianbeliefs. Two intersecting diversity issues – Chinese culture and Christianity – werereferred to in the current study. The development of the CGRS proceeded in accordancewith Page, Pietrzak, and Lewis’s (2001) specific survey development process, in which athree-phase model was conducted. Tasks at Stage 1 include a literature review, scaleselection by consulting with counselling and pastoral scholars, and the development of ana priori scale based on theory and clinical practices. At Stage 2, spiritual fitness andChristian faith-related items were added and the expert validity was established. Aconvenient sampling method and factor analyses were conducted at Stages 1, 2 and 3.The final version of the CGRS was constructed based on the results of the factor analysisat Stage 3, and its validity and reliability were also examined.
Development of CGRS items
Despite intense grief reactions, most people successfully cope with their loss and return tohealthy functioning levels (Bonanno, 2004). Recovering from loss and grief is defined as‘people experiencing the level of positively recovering meaning and sense of power,accepting reality, and gradually alleviating emotional responses and negative response tophysical symptoms, life dysfunction, and strongly missing a deceased loved one’(Neimeyer et al., 2002, p. 235).
Well-known measures of grief include the Texas Inventory of Grief (TIG;Faschingbauer, DeVaul, & Zisook, 1978), the Grief Experience Inventory (GEI; Sanders,Mauger, & Strong, 1979), and the Grief Measurement Scale (GMS; Jacobs et al., 1986).Tomita and Kitamura (2002) critiqued the weaknesses of these scales by indicating thatnone of them can be used to grade the severity of a symptom. In addition, whetherselected items are based on clinical experience, previous literature or both is unclear.Finally, these measures do not present details of a factor analysis (Tomita & Kitamura,2002). Although different grief theoretical frameworks existed, the stages or phases(Kübler-Ross, 1969, 2005; Lee, 2002), tasks (Cowles, 1996), and the Dual ProcessModel (Worden, 1991) were developed to describe a distinct cluster of grief symptomsand its recovering from grief responses from emotional, physical, behavioral, andcognitive perspectives (Fang & Nieh, 2006). In addition, as we already know, theChristian faith is one of the critical variables that partially but directly affects clientrecovery from loss and grief. Therefore, we attempted to develop grief recovery itemsbased on a field interview, practical counselling observation, reshaping availableinventory, and previous literature, from which the concepts of Christian spiritual fitnessand beliefs were added.
Stage 1
Participants and procedures
A letter of invitation indicating voluntary participation in this study was sent to 30Christian churches in northern Taiwan, of which 200 church attendees participated in this
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study. A consent form and an initial Grief Recovery Scale (GRS) (Fang & Nieh, 2006)were sent to those participants. Of the 200 Christian participants, 186 from 25 churchesfilled out the GRS. Data from 172 participants were valid and served as the basis forfactor analysis.
Participants included 43% men and 67% women. The ranking order of deceasedpersons was: father (24%), mother (13%), grandmother (12%), friends (9%), grandfather(7%), grandmother-in-law (7%), grandfather-in-law (4%) and others (16%). They rangedfrom 24 to 62 years of age (M = 42.7 years, SD = 12.5 years). The length of timefollowing the passing of a loved one ranged from one year to 40 years.
Instruments
The GRS, originally developed by Fang and Nieh (2006), consists of 38 items, which areformatted into a four-point Likert-type scale. Of the 1000 college students from 12universities in Taiwan, 931 participants from 20 to 28 years of age (M = 23.3 years, SD =2.4 years) were selected in the data analysis. The factor analysis resulted in six factors:recovering meaning and sense of control (nine items); ongoing physical and emotionalresponses (11 items); life dysfunction (five items); strongly missing a deceased loved one(seven items); accepting reality (three items); and gradually alleviating emotionalresponses (three items). These factors represented 50.55% of the variance. Cronbach’salpha for the total GRS was .92; for recovering meaning and sense of control was .83;for ongoing physical and emotional responses was .87; for life dysfunction was .80; forstrongly missing a deceased loved one was .79; for accepting reality was .71; and forgradually alleviating emotional responses was .60 (Fang & Nieh, 2006).
Data analysis
Data were subjected to factor analysis. A principal component analysis of GRS itemswith varimax rotation showed six factors. This study retained 38 items that loaded at .40or greater on a factor. Eigenvalues and percentage of factor variance were examined usingall items that loaded on the factor. Reliability was assessed by investigating the internalconsistency which was made by computing the Cronbach’s alpha.
Results
Based on previous research findings (Fang & Nieh, 2006) and a theoretical framework(Worden, 1991), six factor solutions were selected, which accounted for 53.68% of thetotal item variance. Cronbach’s alpha for the total GRS was .92; for recovering meaningand sense of control was .73; for ongoing physical and emotional responses was .90; forlife dysfunction was .80; for strongly missing a deceased loved one was .70; for acceptingreality was .73; and for gradually alleviating emotional responses was .76.
Three items failed to load at or above .40 on the factor. Because the criterion forinclusion in the GRS was item factor loading at or above .40, these items were notincluded in the revised version of the GRS. This resulted in a 35-item instrument of therevised GRS.
Stage 2
Based on the assumptions of Worden (1991), two dimensions of the Positive RecoveryDegree and the Negative Recovery Degree were constructed in the grief recovery theory.
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The Positive Recovery Degree consists of recovering meaning and sense of control,accepting reality and gradually alleviating emotional responses, whereas the NegativeRecovery Degree consists of physical symptoms, life dysfunction, and strongly missing adeceased loved one (Fang & Nieh, 2006; Worden, 1991). Despite the previous studiesconfirming that spiritual resources add real value and contribute to people recoveringfrom grief (Chang, 2005; Tagliaferre & Harbaugh, 1990), it has yet to be provenempirically. Research on grief recovery programmes (e.g. Tagliaferre & Harbaugh, 1990;Tan, 2007) is available from religious empirical reports. Although an existing griefrecovery instrument is useful and effective in identifying positive and negative recoveryelements for college students based on Worden’s theoretical framework, severalweaknesses exist. First, the scale was developed from a college population, not from anadult population. Second, the GRS does not contain items that describe spiritual fitness orreligious belief, which are highly valued by Christian participants (Tan, 2007). The lackof religious and spiritual empowerment in the grief recovery process resulted in decreasedcontent validity of the scale from the theoretical and practical perspectives. Finally, it isalso unclear whether GRS items were selected based on clinical experience, previousliterature or both.
To fill in the gap, based on previous research findings, we drafted 10 items relatedto Christian faith and spiritual fitness and conducted interviews with four seniorChristian scholars and two theological seminary professors for consultation. We thencollected suggestions and solicited feedback on item clarity, importance and formattingfrom three Christian counselling psychologists, two school counsellors and two pastoralcounselling professors, all with a minimum of 10 years of counselling experiences andsupervision in school settings in Taiwan. In addition, three of them had constructedinstruments related to counselling techniques. To judge the breadth and appropriatenessof the revised GRS, expert validity was established in this study. Finally, items wereselected and refined to enhance comprehension and understanding in describingspiritual fitness and Christian faith while coping with grief. A one-hour interview washeld and the focus was on the item refinement and the establishment of the expertvalidity. The interview was conducted by the primary researcher who served as aparticipant observer and mediator. The rest of the research team members helped withdata collection and item refinement. Based on the expert feedback, 45 items wereretained in the revised measurement.
Participants
At Stage 2, 120 participants from 15 churches in northern Taiwan and 30 students from aChristian university filled out the revised GRS. Data from the 150 participants served asthe basis for replicating the factor analysis. Participants included 46% men and 64%women. Their ages ranged from 22 to 65 years (M = 38 years, SD = 10.6 years). Thelength of time since the loss ranged from six months to 34 years. Of the 150 participants,39.5% experienced warm support from parents, 46.5% from brothers, 34% from spouses,16% from relatives, 30% from colleagues, 35.7% from pastors or preachers, 4.5% frompsychologists and 6.4% from others.
Instruments
The revised GRS with 45 items was used at Stage 2.
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Data analysis
The procedure was the same as for Stage 1.
Results
Seven- and six-factor solutions emerged and the six-factor accounted for 61% and 62% ofthe total item variance. Following a comparison, the six-factor was selected because therewas only one item on the seventh factor and it was the best theoretical fit with Worden’s(1991) framework. The six factors were common to the results of Stage 2 and the 45items were tailored to two constructs derived from the Dual Process Model (Worden,1991). Cronbach’s alpha for the total revised GRS was .90; for recovering meaning andsense of control was .88; for ongoing physical and emotional responses was .87; for lifedysfunctions was .79; for strongly missing a deceased loved one was .81; for acceptingreality was .61; and for gradually alleviating emotional responses was .79. Thecorrelations between the total score and the six factors were .82, .58, .63, .81, .73 and.42, respectively.
Seven items failed to load at or above .42 on the factor. Therefore, these items werenot included in the final version of the CGRS, resulting in a 38-item instrument of therevised GRS.
To effectively describe the subscale content and to refine the items according toChristian religious belief, the revised GRS was replaced with the CGRS, which includedsix factors: spiritual well-being; recovering meaning and sense of control; ongoingphysical and emotional responses; reassuring faith; strongly missing a deceased lovedone; and life disturbance (Table 1).
Stage 3
Participants and procedures
The primary researcher invited Christian family members who were suffering from theloss of a loved one to participate in this study. A total of 163 Christian participants wereselected at Stage 3, of which 65% were women and 35% were men. Their ages rangedfrom 22 to 58 years (M = 43 years, SD = 11.5 years). The loss was caused by the death ofa grandmother (40%), father (36%), grandfather (33%), others (32%), grandmother-in-law (30%), friend (30%), grandfather-in-law (27.7%), mother (19%), kin (9%), teacher(4%), spouse (2.4%) and child (2.4%). Most participants identified themselves as eitherdevoted Christian (76%) or beginner Christian (24%).
Instruments
The final version of the CGRS was constructed using items that loaded on the same factorat or above .42 at Stage 3. It consists of 38 items and is formatted in a four-point Likert-type scale. The Inventory of Grief (IOF), originally developed by Faschingbauer et al.(1978), and revised by Hsieh, Huang, Lai, and Lin (2007), assesses grief responses offamily caregivers during times of loss. The IOF was used in this study to establish theconcurrent validity of the CGRS. The IOF consists of 35 items and assesses thecaregiver’s emotional, physical, behavioural and cognitive responses. The items wereformatted in a five-point Likert-type scale with 1 = strongly agree, 2 = agree, 3 = slightlyagree or disagree, 4 = disagree and 5 = strongly disagree. A low score indicates low griefresponses, and a high score indicates a high grief reaction described in the item. Internal
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Table 1. Item content and factor loadings on the final version of the CGRS.
Factor Loadings (Stage 2/Stage 3)
Item Content 1 2 3 4 5 6
9. With God by my side, I will feel safeand peaceful.
.80/.80
5. I will no longer feel hurt while thinkingof this incident.
.77/.70
15. Recently, when I think of the death ofloved one, I no longer feel that sorry/regret.
.74/.71
14. Because I have a relation andconnection with God, every time I thinkabout the incident, I do not feel lonely.
.70/.69
11. When I am sad or hurt, through God’swords, I find peace within myself.
.63/.62
6. I have hope for the future due to thefaith I have in God.
.60/.63
16. From the day the incident happened, Istill believe that God always caresabout me.
.58/.51
1. Now I am able to face the fact that myloved one has passed away.
.54/.47
4. With God’s leading and guidance, thegoal of my life is very clear to me.
.40/.42
41. After experiencing the sorrow, I haverealized what the most important things inlife are.
.74/.50
25. I will no longer try to avoid the thingsthat remind me of my loved one.
.70/.68
17. Now, I regain the equilibrium of mylife that was once lost when I lost myloved one.
.68/.63
35. I will no longer feel angry whenthinking of the incident.
.67/.70
40. Now, I am able to understand whyothers cannot feel my sorrow orsupport me.
.67/.57
12. I no longer have occasionalnightmares.
.58/.64
43. I’m no longer troubled by sorrow, andwill treasure every moment I have with myfamily.
.57/.46
23. I think it’s unfair that my loved one haspassed away while I still have to struggleto survive.
.71/.62
22. When I am down because of thatincident, I am not able to stop myself fromovereating.
.71/.47
20. I often find myself driven to distractionand not knowing what I’m doing.
.67/.50
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Table 1 (Continued)
Factor Loadings (Stage 2/Stage 3)
Item Content 1 2 3 4 5 6
26. I’m confused about death incidents andwanting to know why those happen.
.60/.42
33. While my loved one has passed away, Ifind that I lose my ability to take care ofothers.
.56/.45
28. Sometimes, I have a sudden delusionthat my loved one who has passed away isstill alive. For that short period of time, Iforget that she/he has already passed away.
.56/.58
24. Even though my loved one is no longeralive, I believe that God is always aroundme and helps me.
.87/.91
27. I find spiritual comfort and supportwhen I pray.
.80/.80
21. I believe God will listen to my prayersand respond to my needs.
.78/.83
18. I still miss very much my loved onewho has passed away.
.81/.76
32. Memory of my loved one sometimesbreaks into my mind inadvertently.
.78/.76
10. While remembering things related tomy loved one, I still feel sad and hurt.
.71/.70
19. I am often unable to stop thinkingabout things related to my loved one.
.69/.74
8. Sometimes, all of a sudden, I feel like Ican see my loved one standing in frontof me.
.60/.61
39. I still have unconscious chills when Ithink of the incident.
.81/.86
37. Even until now, the sad feelingsometimes causes suicidal thoughts inmy mind.
.77/.81
30. I cannot help but be angry at the deathevent.
.63/.65
38. God will not care about me because Iindulge myself in sad feelings.
.52/.47
34. Even until now, I still cannot sleep wellbecause of that incident.
.44/.49
Note: Extraction method: principal component analysis.Subscale 1: Spiritual well-beingSubscale 2: Recovering meaning and sense of controlSubscale 3: Ongoing physical and emotional responsesSubscale 4: Reassuring faithSubscale 5: Strongly missing a deceased loved oneSubscale 6: Life disturbance
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consistencies were α = .94 for the total scores, α = .89 for initial grief responses, α = .94for the current grief responses and α = .67 for death facts.
Data analysis
The procedure was the same as for Stage 1. Kaiser-Guttman tests were used to determinethe number of meaningful factors resulting from the analysis. Concurrent validity wasconducted to determine if the CGRS correlated well with the IOF, which was previouslyvalidated for measuring the same or related grief construct (Hsieh et al., 2007). Finally,reliability was assessed by investigating the internal consistency which was made bycomputing the Cronbach’s alpha.
Results
Demographic information. Based on the literature review, demographic informationincludes several variables, which may be necessary for further research. The demographicsheet contains questions on age, gender, religious background, length of time after death,level of intimacy, level of discussing death with family members, supportive system andrelationship with the deceased.
Validity. Data were analysed by factor analysis as noted previously. A six-factor solutionwas selected, because it was the most theoretically solid. The factors included spiritualwell-being, recovering meaning and sense of control, ongoing physical and emotionalresponses, reassuring faith, strongly missing a deceased loved one and life disturbance.These factors represent 63.27% of the variance and have good internal consistency.
The factor of spiritual well-being had an eigenvalue of 12.75 and counted for 33.58%of the variance. Items were related to a state in which the positive aspects of spiritualityare experienced, incorporated and lived by a person and reflected in one’s environment aspart of the coping process after significant loss. The factor of recovering meaning andsense of control had an eigenvalue of 3.61 and counted for 9.50% of the variance. Itemswere related to a deeply personal and unique process of changing one’s attitudes, values,feelings, goals or roles as a means of incorporating a new balanced, hopeful andmeaningful life, even with limitations caused by loss. Ongoing physical and emotionalresponses had an eigenvalue of 2.44 and counted for 6.41% of the variance. Items wererelated to personal, emotional, cognitive and physical grief reactions. The factor ofreassuring faith had an eigenvalue of 2.17 and counted for 5.70% of the variance. Itemswere related to the connections and the trusting relationship with God during the periodof loss. The factor of strongly missing a deceased loved one had an eigenvalue of 1.68and counted for 4.43% of the variance. Items were related to a connection with thedeceased one through missing, memory, imagination and pondering. Life disturbance hadan eigenvalue of 1.39 and counted for 3.65% of the variance. Items were related to a highprevalence of pain and sleep disturbances in daily life, resulting from a deceasedloved one.
Concurrent validity is demonstrated where a test correlates well with a measure thathas previously been validated (Miller, McIntire, & Lovler, 2010). Correlations betweenthe CGRS total scores and IOF included emotional responses (τ = −.90, ρ < .01),physical responses (τ = −.81, ρ < .01), behavioural responses (τ = −.97, ρ < .01) andcognitive responses (τ = −.94, ρ < .01). The correlations between the CGRS and IOFscores were significant and support the concurrent validity of the CGRS.
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Reliability. Cronbach’s alpha for the CGRS included total scores .90; spiritual well-being.88; recovering meaning and sense of control .87; ongoing physical and emotionalresponses .74; reassuring faith .81; strongly missing a deceased loved one .82; and lifedisturbance .79. The correlations between the total score and six factors were .84, .76,.73, .66, .58 and .71, respectively. Of the 38 items, three failed to load at .42 on the factor.Because the criterion for item inclusion in the CGRS was factor loading at or above .42,these items were not included in the final version of the CGRS. This resulted in a 35-iteminstrument for the final CGRS.
Discussion
Grief theory originated from Western culture and transferred to Eastern society. Previousliterature has shown that cultural commonality and uniqueness in the grief process and itsrecovery did exist (Bonanno et al., 2005; Fang & Nieh, 2006; Hsu et al., 2004). However,a valid and formal grief recovery scale constructed from the perspective of the AsianChristian is still rare. To fill in the gap, the CGRS was developed to examine TaiwaneseChristian participants’ recovery from grief after a significant loss.
Christian-based Grief Recovery Scale
The development of the CGRS processed through three stages. It is constructed with 35items, and organised into six factors. Those are spiritual well-being, recovering meaningand sense of control, ongoing physical and emotional responses, reassuring faith, stronglymissing a deceased loved one, and life disturbance. Replicated factor analyses resulted inhigh internal consistency. In the final version of the CGRS, all 35 items loaded at orabove .42 on the factor. Therefore, these items were retained and formatted into a four-point Likert-type scale. These factors represented 63.27% of the variance. Most itemsloaded onto one of the six factors at .60 or higher, indicating that the measure of the finalCGRS is reliable according to construct validity (Miller et al., 2010). The CGRS totalscores were also significantly negatively correlated to those of the IOF. These resultssupport the concurrent validity of the CGRS. Finally, Cronbach’s alpha indicated highinternal consistency of the CGRS. However, to refine the CGRS as a research instrument,further evidence for CGRS validity needs to be accumulated.
The research findings may link to the literature. First, Charles-Edwards (2005)postulated that Christians hold the hope that, through Jesus, death is not the end. Inaddition, the hope of the Christian is that faith in God can help people to free themselvesfrom loss. Finally, Marrone (1997) concluded that the cognitive basis of the spiritualexperience and the use of cognitive assimilation, as well as accommodative strategies,during the process of mourning the death of a loved one were effective and meaningful.These Christian values and beliefs are fully reflected in the subscales of spiritual well-being, recovering meaning and sense of control, and reassuring faith. Second, the DualProcess Model, stressed by Worden (1991), described the normal and complicatedprocesses of mourning. In accordance with Worden’s assumption (1991), the CGRSsubscales of strongly missing a deceased loved one and life disturbance were attributed toaspects of the complicated processes of mourning. Nevertheless, the subscale of ongoingphysical and emotional responses can be used to measure the degree of the complicatedprocess of mourning. Third, positive attitudes towards coping with loss and grief can befound from items in the six subscales. Such positive coping strategies consist of positivethinking patterns, seeking spiritual support, collaborative religious coping, spiritual
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connection and benevolent religious reappraisal (Fang & Nieh, 2006; Pargament et al.,1998; Tan, 2007). Finally, death remains a fearful and frightening incident, even in amodern society like Taiwan. The issues of death, loss, grief and bereavement aremysterious, complicated and even unpredictable for people in the Chinese culture. On theone hand, people make every effort to overcome the sense of grief and loss; on the otherhand, they try to connect and communicate with the deceased so that they may restoreimages of the dead or retain a sense of wholeness (Hsu et al., 2004). Hence, the subscalesof strongly missing a deceased loved one and life disturbance are partially reflectedcultural characteristics.
Limitations and suggestions for future research
This study has several constraints that limit its conclusions. First, with the conveniencesampling method, the participants in the development of the CGRS were recruited fromone university and Christian churches in northern Taiwan. The sample may not fullyreflect geographically diverse institutions and cultures. A random sampling method toinclude participants in northern, central and southern regions of Taiwan would greatlyincrease sample diversity and representation. Second, retrospective reporting and relyingon participant self-reporting may result in forgetting or inaccurately rememberingimportant aspects or nuances of particular experiences. Pre-existing beliefs, responsesets and self-presentation style may bias participant reports and personal perceptions.Furthermore, the CGRS was developed with Taiwanese Christian participants, who areaffected by Chinese cultures and Christian beliefs. It is strongly recommended that theCGRS be further used in other cross-culture research. Such results may be able to testifyto its credibility and establish reliability. Finally, this study examined concurrent validityby using the IOF. We suggest that future research should use other various instrumentsrelated to spiritual fitness, religious identity, personal belief system or personality to buildup instrument validity. In sum, it is suggested that future research should include regionaldiversity, various related instruments and multiple assessments.
Application of the CGRS to counselling practice
This study has important implications for practitioners in counselling Christian clients.First, counsellors may use the CGRS to identify the conditions of clients recovering fromgrief and loss in spiritual, emotional, cognitive and behavioural aspects. Therapists andcounsellors could also use the CGRS as a tool to enhance client awareness of the griefrecovery process and to plan step-by-step coping strategies. Moreover, the CGRS can beused as an assessment tool in supportive groups that focus on the interventions of griefand loss. Finally, the CGRS can be used in pre- and in-service counselling and therapeutictraining programmes to help future counsellors, social workers and therapists to enhancethe awareness of their own grief and loss experiences. As a result, counsellingcompetencies to help clients recover from grief may be enhanced.
Conclusion
Each person experiences grief uniquely and each culture manifests grief in various forms.In response to tremendous empirical and practical needs, the CGRS was constructed tomeasure Christian participants’ recovery from grief responses following a significant loss.The CGRS seemingly possesses sufficient validity and reliability to be used by clinical
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psychotherapists, counsellors, social workers and pastoral counsellors. It measuresChristian clients’ grief recovery after the death of a loved one in emotional, cognitive,behavioural and spiritual aspects. Future research could offer sufficient evidence forCGRS validity over time, and include it as one of the vital process- and outcome-basedvariables for both the psychotherapeutic and counselling professions.
Notes on contributorsPeter Jen Der Pan is a professor in the College of Humanities and Education at Chung YuanChristian University, Taiwan.
Liang-Yu F. Deng is an associate professor in the College of Humanities and Education at ChungYuan Christian University, Taiwan.
S.L. Tsai is an associate professor in the College of Humanities and Education at Chung YuanChristian University, Taiwan.
Ho-Yuan Jason Chen is an assistant professor in the College of Humanities and Education at ChungYuan Christian University, Taiwan.
Sheng-Shiou Jenny Yuan is a licensed counselling psychologist in the Student Counseling Center atKainan University, Taiwan.
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