Posttraumatic stress disorder and complicated grief in bereaved parents of the Sewol Ferry disaster exposed to injustice following the loss

Abstract

Background:

Perceived justice after man-made disaster bereavement may involve as a protective factor in the recovery process. However, perceived justice related to posttraumatic stress disorder (PTSD) or complicated grief (CG) after disaster bereavement has not been sufficiently discussed in previous studies.

Aims:

This study aims to assess PTSD and CG in bereaved parents of Sewol disaster and to explore whether perceived justice is related with the diagnostic groups.

Methods:

Bereaved parents of Sewol disaster (N = 122) were interviewed approximately 2 years after the incident. Structured interviews for PTSD and CG were assessed, and perceived institutional justice surrounding the incident was measured. Symptom groups were identified, and multinomial logistic regression was conducted to find whether perceived justice was related with PTSD or CG.

Results:

Participants showed high rates of CG and PTSD, and were classified into the both PTSD and CG group, the CG-only group and the resilient group. The analysis revealed that less perceived justice and being a mother increased the likelihood of having both PTSD and CG. Less perceived justice also showed a tendency to be associated with having CG without PTSD.

Conclusion:

Parents bereaved by the Sewol disaster had high PTSD and CG related to lower levels of perceived justice surrounding the post-disaster period. Post-disaster environment seeking justice may facilitate the natural grieving process or encourage access to effective individual interventions.

Keywords

Disaster bereavement posttraumatic stress disorder complicated grief justice

Introduction

On 16 April 2014, South Korea endured one of the most devastating maritime disasters in the nation’s history, in which 304 people lost their lives. This Sewol Ferry disaster provoked social, political and economic ramifications in South Korea and also raised awareness about preventing and responding to disasters and building a safe society. Because of the number of deaths, many people experienced the loss of family, relatives and close friends, including parents and caregivers of the 246 high school students who lost their lives and four students missing on the way to their field trip. These bereaved parents set up a commission to investigate the incident. However, their psychological and physical conditions have not been sufficiently dealt with.

Acute grief following such loss can evoke complicated and persistent responses, and these psychological states of grief have been called ‘pathological grief’ (Horowitz et al., 1993), ‘traumatic grief’ (Prigerson et al., 1999), ‘prolonged grief (PG)’ (Prigerson et al., 2009) or ‘complicated grief (CG)’ (Horowitz et al., 1997; Shear et al., 2011). Recently, the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5) suggested the term ‘persistent complex bereavement disorder’ (PCBD; American Psychiatric Association, 2013) in Section III, as covering both PG and CG. Also, the International Classification of Diseases, 11th Revision (ICD-11) proposed ‘prolonged grief disorder (PGD)’, highlighting the duration of CG as the key feature (Killikelly & Maercker, 2018).

Although some people show resilient trajectories after bereavement, approximately 10%–15% may show complicated grieving (Bonanno & Kaltman, 1999, 2001). In a community-based study, the prevalence of CG in a general sample was 3.7%, and after major bereavement it was 6.7%. Among the cases, loss of a child had the highest rate (23.6%; Kersting et al., 2011).

Post-disaster bereavement had prevalence rates of 5%–68% in posttraumatic stress disorder (PTSD), 10%–45% in major depressive disorder (MDD) and 14%–76% in CG (Kristensen, Weisaeth, & Heir, 2012). Human-caused disasters increased the risk of mental difficulties, since death is perceived as preventable (Kristensen, Heir, et al., 2012; Norris et al., 2002), and especially loss of a child in disasters has shown increased PG (Johannesson et al., 2009; Kristensen et al., 2010).

Loss of a child is said to be like a violation of the natural life cycle without a warning and can be perceived by the parent as if part of oneself has died (Keesee et al., 2008). In the aftermath of loss of a child, being a mother was shown to be more difficult than being a father (Murphy et al., 1999; Schwab, 1996); also, losing an only child and loss by a violent death increased the risk of PG (Dyregrov et al., 2003; Wijngaards-de Meij et al., 2005).

Previous research also focused on how experiences after the loss complicate the grief process. A prospective research with a community sample of parents bereaved by violence showed that less acceptance and less social support were related to PTSD and intense grief responses (Murphy, Johnson, Chung, & Beaton, 2003). Negative social interactions seemed to be harmful in the grief process (Wilsey & Shear, 2007). A recent study showed that depression after bereavement was associated with perceived stigma surrounding death (Scocco et al., 2019).

Among these devastating experiences after loss, which may well have worsened the complexity of the grieving process, this study focused on perceived justice. Previously, perceived justice related with mental health was mainly studied with victims of human rights violence. Perceived justice such as satisfaction with financial restitution, adequate punishment and apologies from perpetrators was associated with lower levels of PTSD in political trauma (Sonis et al., 2009). Among post-conflict populations of human rights violence, sense of injustice and grief explained PTSD in a well-fit path model (Tay et al., 2017); also, preoccupations with injustice were related to ongoing PTSD and distress in women living in a conflict-affected area (Silove et al., 2014). Preoccupations with injustice were also associated with intermittent explosive disorder (Rees et al., 2013). In one recent study which focused on justice and bereavement, Eisma et al. (2015) reported that ruminating about injustice predicted higher symptoms of CG and depression in loss of a family member.

While numerous discussions point out shattered beliefs about justice after mass disaster and suggest social justice as a core value of disaster response (e.g. Gil-Rivas & Kilmer, 2016; Hobfoll et al., 2007; Inter-Agency Standing Committee, 2007), empirical studies seeking relationship between justice and disaster mental health are scarce. Social justice in disaster response is also an important issue in South Korea, and because culture of a society impacts disaster responses (Hobfoll, 2001), it is important to understand the context of a society and how it relates to disaster response. Historically, South Korea suffered from long-term political conflict and unresolved compensations for victims of organized violence, and institutional response to mass disasters nowadays is criticized for repeating the former failure of victim acknowledgment and righteous compensation (Choi, 2015; Kim, 2014). In this context, social justice to trauma means gaining institutional acknowledgment and compensation. Therefore, our study focused on perceived justice on institutional responses. Perceived justice around rescue, investigation and compensations after man-made disasters may involve as a protective factor in the recovery process.

Perceived justice for bereaved parents of the Sewol had been discussed as a critical issue domestically, and the experiences of passive governmental reactions about rescue and investigation had been a serious social problem in South Korea (Woo, 2014), which eventually initiated the movement to impeach the then-president for corruption. It was also reported that parents refused treatment and claimed justice finding should come before their treatment, and this resulted in a relatively low usage rate of clinical service in the national treatment center specially established after the Sewol disaster (Ansan Mental Health Trauma Center, 2015). However, quantitative data of the relationship between perceived justice and mental health in this population had not been reported. This would be important in seeking appropriate recovery-supporting services. We assumed that less perceived justice would preclude natural grieving or emotional processing and result in complications in the aftermath of loss such as PTSD or CG.

The goal of this study was, first, to assess the symptoms of PTSD and CG in parents bereaved by the Sewol Ferry disaster and, then, to explore whether perceived justice would be related to their symptoms. We expected that perceiving lower levels of justice would be associated with having PTSD or CG, after controlling for parent’s gender.

Methods

Participants and procedure

The data were collected as one part of a large survey of survivors and families conducted by the Special Investigation Commission on the April 16 Sewol Ferry disaster. Institutional review board of Ajou University approved the research. The research team initially contacted all 246 families who had found their children dead from the Sewol Ferry disaster. Families were contacted through the parents on the staff of the 4/16 Sewol Families for Truth and Safer Society, which is a non-governmental parent organization, who invited other parents to participate. The researchers also contacted social support programs in the Ansan area, where the high school was located, and the social workers and activists invited the parents to participate. After initial contact, 133 families refused to participate. Among 113 families, participants were eligible for inclusion if they were parents of the lost children. In 11 families, the participant was some other family member (e.g. siblings of nine families, aunt of one family and grandparents of one family), so they were excluded in this study. Participants had the purpose and descriptions of the study explained to them and completed an informed consent. Of the 128 parents who had started the interview, 6 did not complete both the PTSD and CG interviews because of time constraints. Finally, 122 parents completed the interview; these were parents of 102 of the 246 victimized students (41.5%). The whole interview was administered by licensed clinical or counseling psychologists and lasted for approximately 2 hours. The interview took place in the counseling room arranged by the Commission or in the lounge of the families’ organization.

Measures

Posttraumatic stress and CG

To assess the three major symptoms of PTSD such as re-experience, avoidance and hyperarousal, the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders; 4th ed.) PTSD (SCID-PTSD) was used, which was reported to be reliable and valid for research and practice (First et al., 1996). Symptoms were rated as absent (0) and above subthreshold (1). Diagnosis of PTSD was assessed according to DSM-IV PTSD diagnostic criteria.

CG was identified by the Structured Clinical Interview for CG (SCI-CG; Shear, 2015). Internal consistency (Cronbach’s α = .77), test–retest reliability (interclass correlation = .68) and interrater reliability (interclass correlation = .95) had shown satisfactory results (Bui et al., 2015). SCI-CG includes 12 items rated as absent (1), unsure (2) or present (3). CG is identified when one has significant difficulty in functioning related with at least one of the following four symptoms: yearning and longing, loneliness and meaninglessness, wishing to die, and thoughts and images of the deceased being present; and also with at least two of the following seven symptoms: worry and self-blame, difficulty accepting the loss, shock and emotional numbness, anger, mistrust and detachment, emotional and physical reactions and avoidance of loss being present (Shear, 2015).

Perceived justice

Perceived justice was measured by five items. Professors and licensed clinicians in clinical psychology who had been conducting pilot interviews with the family for another qualitative study of the Sewol disaster created items reflecting institutional justice, which included satisfaction about truth seeking, compensation, punishment charged, apologies given and the role of the government. The five items are listed in Table 1. Participants rated how satisfied they were about each item in a Likert-type scale from not at all satisfied (1) to very satisfied (6). The reliability analysis showed Cronbach’s alpha of .837 which was appropriate.

Table 1.

Rating on each perceived justice item.

		Not at all satisfied, rating = 1n (%)	M	SD
1	People in charge are punished.	114 (93.4)	1.07	0.28
2	The government executed what is expected.	114 (93.4)	1.05	0.22
3	Satisfied about the truth examination, support and compensation.	106 (86.9)	1.14	0.39
4	Compensation for my suffering is made.	114 (93.4)	1.07	0.34
5	People in charge gave an apology.	116 (95.1)	1.05	0.25

Related factors

In addition, depressive mood for 2 weeks, suicidal ideation and suicide attempt in the past year were each inquired about with a single yes/no question. Additional information on demographic variables and participation in a lawsuit was collected. Those who participated in the lawsuit refused government compensation, to contend for a thorough investigation, because receiving government compensation meant that they had to cease requiring the government to take responsibility for the accident.

Data analyses

All analyses were conducted with SPSS 18. Descriptive analyses of perceived justice and related variables were completed. The PTSD and CG groups were identified, and differences between symptom groups were analyzed. Because most of the parents with PTSD also had shown CG, multinomial logistic regression was conducted to identify the predictors according to the diagnostic group membership.

Results

Participant characteristics and perceived justice

Of the parents, 71 were mothers (58.2%) and 51 were fathers (41.8%) with a mean age of 48.8 years (SD = 4.1; range = 40–59 years). Among them, 86 (70.5%) had a high school education, 29 (23.8%) had a university education and 7 refused to report education. Sixty parents (49.2%) had lost their job after the disaster, 11 (9%) were unemployed both before and after the disaster, 45 (36.9%) parents maintained employment and 2 (1.6%) were newly employed; data were missing for four (3.3%). There were 72 parents (59%) preparing for a lawsuit, 33 (27%) parents who accepted government compensation and 17 (13.9%) who refused to answer or had not decided. Table 1 shows the reports of each perceived justice item. Most parents (range = 86.9%–95.1%) rated each item as not at all satisfied, resulting in strong skewness.

Identifying for PTSD and CG and related factors

Data of one participant were missing in identifying CG. Among 121 parents, 109 (90.1%) were diagnosed as CG according to Shear (2015). Identifying PTSD, 14 participants had missing data. Among the 108 parents, 57 (52.8%) parents were diagnosed with PTSD. Among 107 parents who were interviewed with both SCID-PTSD and SCI-CG without any missing data, 57 (53.3%) had diagnoses of both PTSD and CG (the PTSD/CG group), 40 (37.4%) had CG but not PTSD (the CG-only group) and 10 (9.3%) did not show the full criteria for PTSD or CG diagnoses (the resilient group).

In Table 2, group characteristics and statistics for group differences are presented. Age and education were similar among the groups, whereas being a mother showed a group difference. Group differences were also shown in employment change, perceived justice, depressive mood and suicidal ideation. Differences in suicide attempts were not shown statistically; however, six (10.5%) in the PTSD/CG group and two (5.1%) in the CG-only group reported past suicidal attempts post-disaster. No differences were found in the percentage of parent council membership or participating in the lawsuit.

Table 2.

Differences among the PTSD/CG, CG-only and resilient groups.

	PTSD/CG	CG only	Resilient	df	Statistics
Age, M (SD)	48.18 (3.91)	49.06 (4.32)	48.29 (3.20)	2, 97	F = 0.539
Mother, n (%)	40 (70.2)	22 (55.0)	3 (3.0)	2	χ² = 6.644*
Education above university, n (%)	40 (74.1)	29 (76.3)	7 (70.0)	2	χ² = 0.178
Employment change, n (%)	36 (65.5)	11 (28.2)	3 (33.3)	2	χ² = 13.589**
Lawsuit participation, n (%)	40 (75.5)	24 (61.5)	5 (55.6)	2	χ² = 2.758
Member of parent council, n (%)	34 (63.0)	21 (52.5)	3 (30.0)	2	χ² = 3.998
Perceived justice, M (SD)	5.18 (0.63)	5.43 (1.20)	6.60 (2.76)	2, 104	F = 6.129**
Depressive mood in the past 2 weeks, n (%)	45 (78.9)	13 (34.2)	2 (20.0)	2	χ² = 24.859***
Suicidal ideation, n (%)	35 (61.4)	17 (43.6)	0 (0)	2	χ² = 13.573**
Past suicide attempt, n (%)	6 (10.5)	2 (5.1)	0 (0)	2	χ² = 1.868

PTSD: posttraumatic stress disorder; CG: complicated grief.

p < .05, **p < .01, ***p < .001.

According to group difference analyses, being a mother and perceived justice as predictors of group membership were analyzed using multinomial logistic regression (Table 3). Compared to the resilient group, group membership to have both PTSD and CG was predicted by lower perceived justice (odds ratio (OR) = 0.530, 95% CI = 0.325–0.865) and by being a mother (OR = 6.117, 95% CI = 1.249–29.949).

Table 3.

Multinomial logistic regression with the PTSD/CG, CG-only and resilient groups.

	Estimates	SE	Wald	Sig.	Odds ratio	95% confidence interval
	Estimates	SE	Wald	Sig.	Odds ratio	Lower bound	Upper bound
PTSD/CG versus resilient (reference)
Perceived justice	−0.635	0.250	6.457	.011	0.530	0.325	0.865
Being a mother	1.811	0.810	4.993	.025	6.117	1.249	29.949
CG only versus resilient (reference)
Perceived justice	−0.377	0.194	3.785	.052	0.686	0.469	1.003
Being a mother	1.178	0.810	2.116	.146	3.247	0.664	15.869
PTSD/CG versus CG only (reference)
Perceived justice	−0.258	0.231	1.248	.264	0.773	0.492	1.215
Being a mother	0.633	0.432	2.147	.143	1.884	0.808	4.395

PTSD: posttraumatic stress disorder; CG: complicated grief.

Also, compared to the resilient group, the membership to the CG-only group had a tendency to perceive lower justice (OR = 0.686, 95% CI = 0.469–1.003); however, the p value was not significant enough. Being a mother did not predict the membership to be in the CG-only group relative to the resilient group. Finally, perceived justice or being a mother did not predict the membership of the PTSD/CG group relative to the CG-only group.

Discussion

PTSD and CG in bereaved parents

This study sought to discover PTSD and CG symptoms in parents bereaved by the Sewol Ferry disaster who experienced loss amid circumstances of injustice. Even the interview was conducted 2 years after the disaster; the majority of the parents were suffering with CG and showed high rates of PTSD. In our study, 109 (90.1%) parents were suffering from persistent CG. Also, 57 parents (52.8%) were diagnosed as PTSD by the SCID interview, showing a high prevalence. It is in accordance with other studies, however showing a more increased rate. In a research on bereaved parents after violent deaths of children, 21% of mothers and 14% of fathers had PTSD after 2 years, and after 5 years 28% of mothers and 12.5% of fathers maintained PTSD (Murphy et al., 1999; Murphy, Johnson, Chung, & Beaton, 2003). Also, the prevalence of CG has been reported in 14%–76% after both natural and human-made disasters (Kristensen, Weisaeth, & Heir, 2012). Sudden and violent deaths, human-made deaths and loss of one’s child were reported to increase risks (Johannesson et al., 2009; Kristensen et al., 2010; Kristensen, Heir, et al., 2012), and by the fact that the Sewol disaster was related to a human-made death of one’s own child, the characteristic of the event itself may be related to the high prevalence in this study.

Group difference analyses showed that parents with both PTSD and CG had distinctive experiences in changes of employment, and in having depressive mood and suicidal ideation. Past suicidal attempts were also found in both the PTSD/CG and CG-only groups. This reveals clearly that the complicated recovery process after disaster bereavement seriously affects psychosocial adaptations.

Meanwhile, the resilient group of parents without PTSD or CG diagnoses showed the least percentage of depressive mood compared to the diagnosed group and reported no suicidal ideations or past attempts. These parents also showed the least percentage of employment change, indicating that life prior to the disaster is somehow retained. Although we cannot conclude any causation, maintaining employment may indicate restoration-oriented coping that is reported to moderate the relationship between the loss orientation level and grief (Wijngaards-de Meij et al., 2008).

The analysis revealed that justice-seeking action itself, such as participating in a lawsuit, showed no differences among the symptom groups. It may be more related to the result of justice seeking, and not the action, which requires further study to be confirmed. Most of the parents reported very low perceived justice. Satisfaction related with punishment of people in charge, truth seeking, compensations, given support and given apologies were mostly rated as ‘not at all satisfied’ (86.9%–95.1%), which reveals how they experienced the circumstances after the disaster.

Perceived justice associated with PTSD and CG

Seeking whether perceived justice predicted symptoms of PTSD and CG, logistic regression showed that lower levels of perceived justice were associated with being in the PTSD/CG group relative to the resilient group. This had also shown some tendency in the CG-only group relative to the resilient group. Perceived justice did not predict being in the PTSD/CG group compared to the CG-only group.

Whereas previous studies demonstrated that social support protects bereaved people from lasting complex symptoms (Murphy, Johnson, Chung, & Beaton, 2003; Wilsey & Shear, 2007), our study addressed the point that justice building post-disaster may affect psychological recovery.

Making sense of death was reported to be related to grief severity (Keesee et al., 2008). However, the items of our study could not capture how the parents understood and resolved their loss, so we could not make any conclusions. It is difficult for parents to find any meaning in the sudden death of their child, or even getting a sense of understanding the inexplicable (Murphy, Johnson, & Lohan, 2003). Anyhow, injustice maintains unanswered questions precluding meaning making and persists rumination regarding the incident (Kristensen, Weisaeth, & Heir, 2012), which may function as a risk factor. In these kinds of circumstances, society needs to help keep trust that wrongdoings will be dealt with and these man-made disasters will come to an end. However, in the Sewol Ferry disaster, not only did the parents experience loss and trauma, their trauma had a quality of betrayal, which may have accounted for the persistent symptoms. When harm or violation occurs in a dependent relationship, violation of trust arises and threatens beliefs about self, others and the world (Freyd et al., 2005). Perceived injustice reflects violation of trust in society and the government. Boelen et al. (2016) discussed that negative cognitions of self and life were related to higher probabilities of PG and depression, so we may suggest that a justice-seeking environment after a loss may moderate the effect of negative cognitions and facilitate recovery. Also, it has been reported that low forgiveness was related to poor psychiatric health in survivors of human rights violence (Kaminer et al., 2001). Since forgiveness is a response following truth recognition and ‘having their questions answered’ in the perspective of restorative justice (Sofka, 2016), reconstruction of justice may be crucial in accelerating the natural grieving process.

The analysis also showed that being a mother increased the likelihood to maintain PTSD and CG relative to be resilient, as is confirmed by numerous studies (Murphy et al., 1999; Schwab, 1996). It may also require some cultural understanding that since mothers’ identities are more closely connected with their children in Korean culture, being a mother may have increased the risk.

Clinical implications

Searching for implications, we would stress that trajectories of symptoms may differ if social conditions seek justice for the bereaved in man-made disasters. Although individual intervention had proven to be efficacious for CG (e.g. Nam, 2016; Shear et al., 2016), our study indicates that, in particular psychosocial circumstances, a collective perspective focusing on building justice is crucial for the grieving process. This is in line with efforts to promote community resilience as the ‘adaptive capacity’ that buffer adverse effects and lead to resilient post-disaster trajectories (Norris et al., 2008). Collective efforts to rebuild from the loss, such as by examining the cause and revealing the truth, people who are in charge taking responsibilities, and cooperation and support from the government and society will be pivotal steps in enhancing community resilience.

Cultural understanding about loss of a child in Korea should also be taken into consideration, because identity as a parent is closely linked to one’s child in this culture. Some Sewol parents claimed that they have refused treatment or any service from clinicians before justice is brought, since in Korean culture being cured or getting free from grieving over the loss of a child is commonly thought of as meaningless and may worsen guilt. Therefore, for effective individual treatment, seeking truth and bringing justice to build a therapeutic environment should be considered in advance for bereaved parents in Korea.

In addition, although mothers seemed to show more symptoms, fathers may have impairing grief symptoms that are not captured by PTSD or CG. It was reported that intervention effectiveness differs for mothers and fathers (Murphy et al., 2002), so further research is required to depict the grieving phenomenon of fathers and adapt adequate interventions for them.

Limitations and future research

Our study has limitations for being generalized to other bereaved people, since our study participants were related to a very specific disaster. Since the skewness of perceived justice was severe, and the Sewol Ferry disaster was human made, this characteristic experience of our participants may have contributed to the distinctive symptom rates, which may differ from others bereaved in a different context. Also, the participants may over-represent particular group of parents, since data collection was made mainly through parents who came to gatherings; parents who are isolated or do not participate in meetings may not be well represented in our study. In addition, risk or protective factors related to PTSD or CG were not sufficiently examined, because we focused on experiencing justice, and missing data for several variables unfortunately hindered broad analyses. How the resilient group sought adaptation cannot be answered by our data, so, furthermore, a prospective research is required to confirm any causal relationships. When political and social environments surrounding the Sewol disaster in Korea change, it may be useful to seek whether a different justice climate affects the parents’ symptoms or their motives in seeking treatment. Future research identifying justice-seeking society as an element of community resilience may broaden our understandings to disaster bereavement.

Conclusion

Parents bereaved by the Sewol Ferry disaster had high rates of PTSD and CG related to the perceived injustice surrounding the incident. In a culture where parents’ identities are highly linked to their children, individual treatment approaches may not be sufficient. Considering the culture and context surrounding the bereavement, a collective perspective of seeking justice may facilitate the natural grieving process or encourage access to effective individual interventions for bereaved parents.

Footnotes

Acknowledgements

The authors gratefully acknowledge the contributions of the 4.16 Families for the consultation and participation for this work. Also, we thank Hyeseon Hong for coordinating the interviews and collecting data, Simyang Heo for data organization, and the interviewers for their supportive work.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was supported by the Special Investigation Commission on the April 16 Sewol Ferry disaster, South Korea. This funding source had no role in this study.

ORCID iD

Hyunjung Choi

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