The impact of grief rumination on grief among Chinese bereaved parents who lost their only child: A mixed study

Abstract: Child-loss is often considered as one of the most painful bereavement, which is associated with a higher prevalence of prolonged grief disorder (PGD). Chinese bereaved parents over the age of 49 who have lost their only child are referred as shidu parents. They face not only significant loss but also societal pressures and are vulnerable to PGD. Grief rumination appears to play a crucial role in the development and maintenance of PGD. The current study employed a mixed method with explanatory sequential design to explore the impact of grief rumination on grief severity among shidu parents. In Study 1, a cross-sectional questionnaire survey was conducted among 310 shidu parents to evaluate the relative importance of rumination on grief. Relative weight analysis indicated that rumination had a greater impact on grief than the three key factors proposed in Cognitive Attachment Model of prolonged grief (integration of autobiographical memory, grief beliefs, and avoidance). In Study 2, a follow-up survey with an interval of about 5 months was conducted among 265 parents who lost their only child in the past 5 years. Results of hierarchical multiple regression analyses suggested that rumination about meaning and rumination about injustice were significantly positively correlated with current grief levels (Beta = 0.47 and 0.36, p < 0.001). After controlling for covariates and baseline grief levels, only meaning rumination significantly predicting grief severity five months later (Beta = 0.29, p = 0.002). Rumination about social relationships, rumination about personal reactions and counterfactual thinking were not significantly related to grief symptoms. Study 3 employed a qualitative method to conduct in-depth interviews with 11 shidu parents. Results of reflexive thematic analysis revealed that each dimension of rumination had both maladaptive and adaptive influence. Cultural factors, particularly Confucian and collectivist culture such as “having a child to continue the family bloodline”, “raising children for old age support”, and “life and death are determined by fate”, played important roles in the impact of rumination on grief. Meaning rumination produced primarily negative outcomes, whereas the effects of counterfactual rumination were complex. Shidu parents who reported injustice rumination eventually attributed the child-loss to fate, thereby alleviating their grief reactions, which might explain why injustice rumination did not have a long-term negative impact on grief. The findings partly validate and extend the Cognitive Attachment Model hypothesis that rumination can exacerbate emotional distress and hinder the integration of the death event into autobiographical memory through avoidance behavior. Additionally, rumination may trigger or maintain negative repetitive thinking or negative self-evaluations, further affecting grief reactions. These results highlight that rumination is a significant factor influencing the grief of shidu parents, suggesting that meaning reconstruction therapy could be beneficial in helping shidu parents alleviate grief.