Exploring prolonged grief disorder through Iranian cultural beliefs: a qualitative thematic analysis

ABSTRACT

Background: Prolonged Grief Disorder (PGD), recently recognized in the DSM-5-TR and ICD-11, manifests differently across cultural contexts. Although grief is a universal human response to loss, its expression and interpretation are shaped by culturally specific moral and social norms. With limited research on Iranian cultural influences on prolonged grief symptoms, this study examined how culturally embedded beliefs shape the moral meanings and social expectations of grief among individuals meeting PGD screening criteria in Iran.

Methods: Semi-structured interviews were conducted with seventeen bereaved adults in Tehran (aged 21–59 years) who met PGD screening criteria based on the PG-13-R and the International Prolonged Grief Disorder Scale (IPGDS). Data were analyzed inductively using reflexive thematic analysis to capture culturally grounded meanings shaping prolonged grief experiences.

Results: Five interrelated themes were identified: (1) causal attributions, (2) cultural mourning symbols, (3) paradoxical expectations surrounding mourning, (4) distressing religious beliefs, and (5) harmful cultural clichés. Participants linked these thematic patterns to guilt, social pressure, and spiritual conflict, and described them as relevant to their PGD symptom experiences.

Conclusions: Findings suggest that participants described their PGD-related distress as shaped by culturally salient meanings and social evaluations of grief. These results underscore the need for culturally attuned assessment and intervention strategies that address moral and social narratives surrounding mourning.

HIGHLIGHTS

• The study identified culturally grounded beliefs and expectations that recurred across participants’ accounts of prolonged grief disorder in Iran.

• The thematic analysis identified five interrelated themes – causal interpretations of loss, cultural symbols of mourning, paradoxical expectations surrounding mourning, distressing religious beliefs, and harmful cultural clichés.‏

• These findings highlight the need for culturally sensitive assessment and intervention for PGD symptoms that address the cultural narratives and expectations linked to ongoing distress.

1. Introduction

Losing a loved one is among the most profound and universal human experiences. The immediate aftermath of bereavement is often marked by waves of grief, longing, and disbelief, as individuals struggle to make sense of life without the deceased. However, for most people, this acute emotional pain gradually softens over time. As they reengage with daily routines, social connections, and meaning-making processes, grief begins to transform rather than disappear – a resilient trajectory well documented across diverse populations (Bonanno, 2004; Shear, 2015; Stroebe et al., 2017). Within several months, many bereaved individuals experience a natural transition from acute grief – characterized by pervasive distress and preoccupation with the loss – to integrated grief, a state in which the loss remains significant but no longer disrupts everyday functioning (Nielsen et al., 2025).

While most bereaved individuals gradually adapt to the reality of the loss, a minority experience a disruption in this natural healing process. Some develop what was historically termed complicated grief – a stalled adaptation process marked by severe, persistent symptoms that disrupt daily life. Over time, however, psychiatric nosology refined this construct, and when such reactions extend beyond culturally normative timeframes and fulfil established diagnostic criteria, they are formally classified as Prolonged Grief Disorder (PGD). This disorder is recognized in both the DSM-5-TR and the ICD-11. The DSM-5-TR specifies a minimum duration of 12 months after bereavement for adults (6 months in children/adolescents) and requires persistent yearning or longing, or preoccupation with the deceased, accompanied by additional symptoms such as identity disruption, disbelief, avoidance of reminders, intense emotional pain, difficulty reengaging with life, emotional numbness, feelings of meaninglessness, and profound loneliness, along with clinically significant distress or impairment (American Psychiatric Association, 2022). The ICD-11 applies a 6-month threshold and stipulates that grief must exceed cultural, social, or religious norms, leading to significant distress and functional impairment (World Health Organization, 2019). Conceptually, PGD is distinguished from major depressive disorder and post-traumatic stress disorder (PTSD) by its enduring separation distress – manifested as persistent longing or preoccupation with the deceased – rather than the pervasive anhedonia of depression or the threat-based re-experiencing characteristic of PTSD (Eisma, 2023).

Epidemiological studies have shown that only a minority of bereaved individuals develop PGD. While early meta-analyses estimated prevalence rates of approximately 10% (Lundorff et al., 2017), more recent population-based research applying ICD-11 and DSM-5-TR criteria has reported lower and more variable rates, typically ranging from 5% to 13% (Comtesse et al., 2024; Treml et al., 2024). In addition, some studies have found even lower prevalence estimates within bereaved samples, such as Rosner et al. (2021), who reported rates of approximately 3–4% depending on diagnostic criteria. Despite its relatively low prevalence, PGD is clinically significant. If left untreated, it often follows a chronic course and is associated with impairments in quality of life, increased suicidality, and high rates of comorbid depression, anxiety, and PTSD (Eisma, 2023; Prigerson et al., 2009). Research has identified several risk factors that increase vulnerability to PGD – including sudden or violent bereavement, the loss of a child or partner, insecure attachment styles, prior mental health difficulties, limited social support, and ongoing post-loss stressors, whereas supportive social networks, meaning-making processes, and reinforcing mourning rituals act as protective factors (Buur et al., 2024; Lobb et al., 2010).

Although grief is deeply personal, it never occurs in isolation. As Breen and colleagues (2022) emphasize, the experience of loss is always situated within shared cultural and social frameworks that shape how grief is expressed, interpreted, and supported. This perspective highlights a critical duality: grief is both an intrapsychic and a sociocultural phenomenon. Accordingly, understanding PGD requires examining not only individual emotional processes but also the collective expectations that define what is considered ‘normal’ or ‘pathological’ mourning (Eisma, 2023).

From this broader view, culture functions as the primary lens through which grief is experienced, regulated, and made meaningful. While bereavement is universal, societies differ in how they determine appropriate expressions of sorrow, prescribe its duration, and assign moral significance to suffering (Klass et al., 1996; Neimeyer, 2001; Parkes et al., 1997). As noted in ecosocial and cultural psychiatry, experiences of distress – including grief – emerge within social ecologies shaped by shared narratives, communal obligations, and moral expectations (Kirmayer, 2019; Kirmayer, 2025). These culturally shared norms delineate the boundaries between adaptive and maladaptive grief and influence whether prolonged grief becomes viewed as a clinical disorder (APA, 2022; WHO, 2019).

Across diverse contexts, cultural and religious traditions provide adaptive frameworks that help mourners reconstruct meaning and restore social connectedness. Rituals such as funerals, memorial gatherings, and commemorative practices not only facilitate emotional regulation but also reaffirm communal solidarity in the aftermath of loss (Klass et al., 1996; Neimeyer, 2001; Stroebe & Schut, 2016).

In Western settings, collective remembrance and spiritually grounded narratives facilitate acceptance and re-engagement with life (Bonanno, 2004; Shear, 2015; Stroebe et al., 2017). Likewise, in non-Western contexts, mourning repertoires often provide moral order and social cohesion. In contemporary Turkey, mevlit prayers and family-based recitations strengthen social ties and provide a shared moral narrative around death (Köroğlu & Durat, 2025). In Iran, condolence visits, commemorative ceremonies (on the third, seventh, and fortieth days), and charitable acts in the name of the deceased offer emotional structure and communal validation (Karimitar, 2019; Shoraka et al., 2022). Such structured rituals often render grief publicly visible and socially regulated (Shoraka et al., 2022). Qualitative evidence from bereaved Iranians further suggests that these collective ceremonies function as key mechanisms for emotional expression and social support, often involving sustained family and community presence in the home during the first week after the loss (Asgari et al., 2025). Consequently, when COVID-19 restrictions curtailed funerals and post-loss gatherings, mourners described their grief as unexpressed and disenfranchised, characterized by unresolved sorrow, persistent distress, and heightened guilt related to the circumstances of death and limited opportunities to say goodbye (Asgari et al., 2025). Consistent with these accounts, during the COVID-19 pandemic, restrictions on condolence gatherings and commemorative rituals were associated with increased reports of prolonged grief symptoms among bereaved Iranians (Aliyaki et al., 2024).

Yet the same cultural frameworks that provide structure and meaning can also constrain individual grieving and, in some cases, be associated with more persistent distress. Prescriptive norms dictating how long one should mourn or how visibly emotions should be displayed may transform grief from a personal process into a moral obligation. When mourners deviate from these expectations, they often encounter criticism, guilt, or shame – social reactions that may complicate psychological adaptation. Empirical evidence indicates that rigid social constraints on emotional disclosure and expression are associated with poorer adjustment and heightened symptoms of PGD (Burke & Neimeyer, 2012; Juth et al., 2015).

In Muslim-majority contexts such as Turkey, religious and funeral rituals may become constraining when they are experienced as obligatory or externally imposed, reducing individuals’ sense of control and hindering emotional recovery (Aksoz-Efe et al., 2018). Similarly, Iranian mourning is deeply moralized, prescribing how one should dress, behave, and feel during bereavement; public expectations to maintain visible sadness, avoid joy, or continue mourning for extended periods may turn grief into a socially enforced identity (Karimitar, 2019; Shoraka et al., 2022). Moralized religious interpretations – such as viewing death as divine punishment or as a test of faith – can intensify guilt and spiritual conflict, thereby amplifying the emotional distress characteristic of PGD (Lee et al., 2013; Neimeyer & Burke, 2011; Pargament, 1997).

Although cultural beliefs shape how grief is understood and expressed, their role in the presentation of prolonged grief symptoms consistent with PGD has received little attention in Iran. Qualitative inquiry is, therefore, essential for capturing meanings and experiences that standardized measures cannot access. Research on prolonged grief symptoms in Iran remains limited and has largely focused on epidemiological estimates and psychometric validation of screening tools. For example, Ashouri et al. (2025) reported that 10.9% of bereaved university students in Tehran met screening criteria for elevated prolonged grief symptoms, highlighting the need for culturally grounded qualitative inquiry. Accordingly, this study aims to explore how bereaved Iranian adults who meet PGD screening criteria describe their cultural beliefs regarding the interpretation and expression of prolonged grief, contributing grounded insights to the limited qualitative literature.

2. Methods

This study employed an interpretive qualitative design using semi-structured interviews to explore culturally salient beliefs related to prolonged grief symptom experiences among bereaved adults meeting PGD screening criteria in Iran. We used reflexive thematic analysis (Braun & Clarke, 2006, 2021) with an inductive, data-driven approach to develop themes from participants’ narratives rather than from predetermined categories (Braun & Clarke, 2006, 2021).

2.1. Participants and recruitment

Seventeen participants (10 women, 7 men), aged 21–59 years (M = 44.6, SD = 12.5), were recruited in 2025 through the Tehran Grief Foundation using purposive sampling. This sampling strategy was selected to ensure diversity in age, gender, education, marital status, and type of loss (Patton, 2015). Recruitment involved posting study announcements on the Foundation’s website and social media platforms, as well as distributing flyers in the centre's waiting area. Interested individuals contacted the researcher directly to receive study information and arrange an interview. Participants received a book as a token of appreciation for their time.

Eligibility criteria included: (a) being at least 18 years old, (b) having experienced the bereavement of a close relative at least 12 months prior to participation. Although the IPGDS assesses the ICD-11 six-month threshold, in the present study a minimum of 12 months since the loss was required to align with DSM-5-TR criteria and to avoid the inclusion of acute grief cases, and (c) meeting screening criteria for prolonged grief disorder symptomatology.

Exclusion criteria included severe psychiatric disorders (e.g. psychosis, bipolar disorder), active substance dependence, or significant cognitive impairments that could hinder participation in interviews. Recruitment ceased when the dataset was judged to provide sufficient depth and variation to support a rich thematic account, and when additional interviews were unlikely to meaningfully extend the developing interpretation. Participant characteristics are summarized in Table 1.

Table 1.

Participant characteristics (N = 17).

Variable	Category	n	%
Age (years)	20–29	3	17.6
	30–39	3	17.6
	40–49	3	17.6
	50–59	8	47.1
Gender	Female	10	58.8
	Male	7	41.2
Marital status	Single	3	17.6
	Married	10	58.8
	Widowed	4	23.5
Education level	High school	4	23.5
	Bachelor’s degree	10	58.8
	Master’s degree	2	11.8
	Doctorate	1	5.9
Type of loss	Child	6	35.3
	Father	3	17.6
	Mother	2	11.8
	Spouse	3	17.6
	Brother	2	11.8
	Sister	1	5.9
Time since bereavement	12–36 months	4	23.5
	37–60 months	6	35.3
	> 60 months	7	41.2

2.2. Data collection

Semi-structured interviews were conducted in person over three months (February–April 2025). Interviews took place in a private consultation room at the Tehran Grief Foundation to ensure comfort and confidentiality. The interview guide was developed by the first author in consultation with the supervisor, focusing on eliciting cultural beliefs. Several questions conceptually overlapped with the domains of the Bereavement and Grief–Cultural Formulation Interview (BG-CFI; Smid et al., 2024), which served as a useful reference to ensure cultural relevance. Example questions included: ‘When you think about the death of your loved one, what kinds of beliefs or thoughts come to mind?’ and ‘In the culture or community you live in, what beliefs about grief have you heard that influenced your experience?’ Follow-up probes were used to clarify and deepen responses. The complete interview guide is provided in Appendix A.

All interviews were conducted in Farsi, audio-recorded with participants’ consent, and lasted between 53 and 98 min. Transcripts were prepared verbatim and anonymized by replacing identifying information with participant codes (e.g. P1, P2). Data were securely stored on password-protected devices accessible only to the research team.

2.3. Researcher reflexivity

The first author is a clinical psychologist with personal experience of bereavement, which supported empathy and rapport while also shaping the researcher’s interpretive lens. Reflexive practice was maintained throughout, including analytic memo-writing and reflective notes after each interview to document evolving assumptions and interpretations. Regular peer debriefing with an experienced qualitative researcher provided critical dialogue on emerging interpretations and theme development, supporting analytic rigour and a balance between insider sensitivity and critical distance.

2.4. Instruments

Two validated Persian versions of standardized measures were used to screen participants:

1. Prolonged Grief-13 Revised (PG-13-R) – aligned with DSM-5-TR criteria. The Persian version has demonstrated excellent reliability (ω = .93, test–retest r = .89) and validity in Iranian samples (Ashouri et al., 2024).

2. International Prolonged Grief Disorder Scale (IPGDS) – aligned with ICD-11 criteria. The Persian version confirmed a valid four-factor structure with Cronbach’s α = .82–.93 (Yousefi et al., 2025).

All 17 participants completed both screening instruments, and PGD classification followed the instruments’ recommended diagnostic algorithms. PG-13-R severity was computed by summing items Q3–Q12 (range 10–50); DSM-5-TR criteria required the recommended symptom pattern, functional impairment, and a loss ≥12 months. IPGDS screening used the standard 13-item scale (IPGDS-13; range 13–65) and the ICD-11 algorithm (core symptoms and impairment; duration ≥6 months). In the present sample, internal consistency was good (PG-13-R: α = .84; IPGDS: α = .89), and mean severity scores were PG-13-R M = 39 and IPGDS-13 M = 51. All participants met PGD criteria on both instruments (100% agreement).

2.5. Data analysis

The analysis followed Braun and Clarke’s (2006, 2021) reflexive thematic analysis and proceeded through six recursive phases: familiarization, coding, generating initial themes, reviewing themes, defining and naming themes, and producing the report. Coding was conducted inductively and reflexively, with the first author taking primary responsibility for coding and theme development. Regular analytic discussions with the supervisory team were used to deepen interpretation, challenge assumptions, and refine theme boundaries. Analytic memos were maintained throughout to document evolving interpretations and reflexive decisions. Data management and coding were supported by MAXQDA 2024.

2.6. Methodological integrity

To support methodological integrity, we emphasized reflexivity and analytic transparency throughout the study. Reflexive notes and analytic memos were kept to document evolving assumptions and interpretations, and an audit trail captured key analytic decisions and revisions during coding and theme development. Regular peer debriefing sessions provided critical dialogue to challenge assumptions and refine theme boundaries. A thick description of participants and context was provided to support readers’ assessment of transferability. Together, these strategies were used to enhance the study’s trustworthiness.

2.7. Ethical considerations

The study protocol was approved by the local Institutional Review Board (Approval ID: IR.SBU.REC.1403.123). All participants provided written informed consent and were assured of confidentiality and voluntary participation. The study was conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments.

3. Results

A total of 17 bereaved Iranian adults participated in the study (10 women, 7 men; M age = 44.6 years, SD = 12.5). In-depth semi-structured interviews (53–98 min) generated a rich dataset. Using reflexive thematic analysis, we developed five overarching themes with related subthemes that reflected culturally salient meanings in participants’ accounts of prolonged grief symptoms.

3.1. Overview of themes

Using a reflexive thematic analysis, we identified five overarching themes that describe culturally embedded beliefs and meanings related to prolonged grief experiences among Iranian adults. Participants described their PGD-related distress as socially evaluated and morally framed, including collective judgments, symbolic practices, and perceived obligations surrounding mourning. Table 2 summarizes the themes and subthemes.

Table 2.

Themes and Subthemes Reflecting Cultural Beliefs and PGD Symptom Experiences in Iran.

Theme	Subthemes
Theme 1. Causal Attributions	1.1 Attribution of Death to the Mourner’s Wrongdoing 1.2 Attribution of Death to Magic and Sorcery
Theme 2. Cultural Symbols of Mourning	2.1 Black as a Symbolic Color of Mourning 2.2 Sadness as a Required Mourning Performance
Theme 3. Cultural Paradoxes of Mourning – ‘End it now’ vs. ‘Keep mourning’	3.1 Pressure to Prematurely End Mourning 3.2 Pressure for Continued Public Mourning
Theme 4. Distressing Religious Beliefs	4.1 Perceiving Death as Unjust for Believers 4.2 Expectation to Suppress Emotional Expression Because of Faith
Theme 5. Harmful Cultural Clichés	5.1 Distressing the Deceased Through Excessive Lamenting (kâse-ye zahr, literally bowl of poison) 5.2 Belief That Grief Fades After Burial (khâk sarde, literally cold soil)

3.2. Theme 1: causal attributions

In this study, some participants described searching for a perceived ‘cause’ of death as part of their mourning experience. Such explanations were articulated within families and communities through moral, social, or supernatural frameworks. While such explanations may provide meaning, they frequently intensify feelings of guilt, injustice, or anger. Instead of facilitating adjustment, these attributions can complicate the grieving process by trapping mourners in cycles of blame, self-doubt, and suspicion.

3.3. Subtheme 1.1: attribution of death to the mourner’s wrongdoing

Several participants reported that others explicitly linked their bereavement to their own moral failings. Such moralization of loss placed a heavy burden of shame and guilt on the mourner:

Other people’s judgments really hurt me. A while ago, someone said, ‘Maybe you earned illicit money or overcharged people, and that is why this befell you.’ That torments me, because my spouse and I have truly been benevolent and good people. (P3, male, 56, lost child)

They say things like, ‘You must have done something bad, so God tested you this way.’ In the first days after the burial, a neighbor told me, ‘Your husband was so young – what had you done before that this happened to you? Did you wrong someone so that he died like this? (P6, female, 47, lost spouse)

These accounts highlight how social judgments convert loss into a form of moral trial, amplifying suffering by layering shame and perceived divine punishment onto the already painful experience of bereavement.

3.4. Subtheme 1.2: attribution of death to magic and sorcery

Other participants explained their loss through supernatural causes, such as sorcery or witchcraft, which are deeply embedded in local folk beliefs. Such interpretations often emerged in contexts of interpersonal conflict, where strained relationships provided fertile ground for suspicion:

My daughter always had problems with her in-laws; they used to bother her. I am sure they bewitched her – that is why this calamity happened to her. (P2, female, 58, lost child)

Yes – envy … My sister was very talented and independent, with offers from several countries. People envied her. I suspect something like sorcery caused her illness and death. (P12, male, 33, lost sister)

While these beliefs offered mourners a way to interpret an otherwise incomprehensible loss, participants also described them as being accompanied by mistrust and hostility within families and communities. In their accounts, grief became intertwined not only with sorrow but also with fear and social conflict, which was experienced as complicating the grieving process. Overall, this theme suggests that moralized and supernatural explanations can position grief as a socially mediated moral trial and may be associated with persistent feelings of guilt and mistrust that some participants perceived as constraining adjustment.

3.5. Theme 2: cultural symbols of mourning

In participants’ accounts, visible symbols of mourning are central markers of socially ‘appropriate’ grief. These symbols both provide a framework for mourners and impose external expectations. While they may foster solidarity in the short term, they often complicate adjustment by shifting the focus of mourning from inner needs to display outward.

3.6. Subtheme 2.1: black as a symbolic color of mourning

Wearing or displaying black (including on social media) is the dominant symbol of mourning in Iranian society. Participants emphasized that this was less a personal choice than a form of social compulsion:

One example is when they say you must wear black – especially when you go out. It puts psychological pressure on me. I want to imagine my husband is in heaven and wear blue, but I cannot – people will talk behind my back that I wore light-colored clothes. (P9, female, 44, lost spouse)

It has been several years now, but my Facebook profile photo is still black. If I put another picture, people will say I must have forgotten my child. (P14, female, 55, lost child)

Such accounts illustrate how external expectations turn symbols of mourning into measures of loyalty to the deceased. Failure to comply risks social judgment, trapping mourners in an outward performance that can complicate their grieving process.

3.7. Subtheme 2.2: sadness as a required mourning performance

Beyond clothing, participants described the expectation to maintain a visibly sad demeanour. Any sign of joy or relief risked being interpreted as disrespect toward the deceased:

Yes, there are many things. For example, sometimes when I feel okay or go on a trip, I feel guilty – because when you lose someone, you are supposed always to look sad or wail; you should look like a depressed person. (P4, female, 24, lost father)

Can you believe it? For a while, I had gotten better, but I tried not to show it. I thought laughing – especially laughing out loud – was wrong, and in groups I forced myself to appear droopy and sad. While people should encourage us for working so hard to get even a little better. (P7, female, 36, lost brother)

These accounts reveal how mourners are compelled to ‘perform sadness.’ Even brief moments of relief are shadowed by guilt, delaying healthy adjustment to loss. While symbolic rituals offered participants a sense of continuity, social expectations often imposed conflicting messages about how long grief should be visible. Together, these accounts reveal how public symbols of mourning, though intended to honour the deceased, often bind mourners to social expectations that constrain authentic healing.

3.8. Theme 3: cultural paradoxes of mourning  – ‘end it now’ vs. ‘keep mourning’

Mourners described facing contradictory social pressures. On the one hand, they were encouraged to terminate the mourning period promptly. On the other hand, they were expected to maintain visible mourning practices as a demonstration of loyalty to the deceased. Caught between these conflicting demands, mourners often felt that no response would be judged as appropriate. This paradox complicates the grieving process by undermining authentic emotional expression.

3.9. Subtheme 3.1: pressure to prematurely end mourning

Some participants were told they had mourned long enough and should stop grieving, as if grief had an expiry date:

My acquaintances did not give me any chance to get better. I did not have influenza to recover after one week. I wanted to tell them, ‘If your child had died, would you immediately be fine?’ (P17, female, 59, lost child)

Yes – imagine, in the middle of that awful time, a friend told me, ‘It has been 40 days, and you are still crying? That is enough – you should get back to life.’ It felt like an insult. (P1, female, 21, lost brother)

These experiences show how grief is socially treated as time-limited, leaving mourners feeling guilty or inadequate for not recovering quickly.

3.10. Subtheme 3.2: pressure to continued public mourning

Conversely, some participants described being criticized for resuming normal activities or appearing cheerful, as though doing so betrayed the deceased:

A few months had passed. A friend saw me at a party and said, ‘I am surprised you are here after what happened to you – as if everything is over.’ It is like because relatives and neighbors say, ‘she is not a mourner anymore,’ you feel forced to show that you are. (P7, female, 36, lost brother)

When I said we went on a trip to the north at my brother’s insistence, later I heard relatives say, ‘Was not he very attached to his wife? How quickly he got over it.’ I still cannot forget that remark. (P13, male, 54, lost spouse)

Such pressures trap mourners in a paradox: ending mourning too soon suggests disloyalty, while continuing it too long signals weakness. This contradiction intensifies distress and complicates adaptation to loss. This theme underscores how contradictory moral expectations about grief duration create emotional paralysis, reflecting broader tensions between social conformity and individual need.

3.11. Theme 4: distressing religious beliefs

Religious beliefs played a burdensome role in participants’ experiences of grief. For some, strong religious commitment intensified feelings of injustice and abandonment, as faith-based explanations failed to align with the magnitude of their loss. For others, social expectations tied to religiosity constrained their emotional expression, fostering guilt or suppression rather than solace. Across accounts, faith emerged as a source of psychological pressure rather than comfort, complicating the grieving process and limiting opportunities for authentic emotional release.

3.12. Subtheme 4.1: perceiving death as unjust for believers

Some participants felt that their religious observance should have protected them from such loss and experienced the death as deeply unjust:

I keep telling myself my spouse and I were very observant with prayer and fasting. So, what was this calamity that befell us? I told you he never missed praying at the appointed time. (P3, male, 57, lost child)

I am very angry. This was not my due. For years I read the Qur’an in Ramadan and mourned for Imam Husayn. Now I must live as a widower for the rest of my life. (P16, male, 51, lost spouse)

Such interpretations entangle grief with anger at perceived divine injustice, leaving mourners spiritually unsettled and emotionally burdened.

3.13. Subtheme 4.2: expectation to suppress emotional expression because of faith

Participants described how people around them expected them to restrain emotional expression because of their religious faith. Expressions of intense grief were often discouraged, as faith was perceived to require composure, acceptance, and emotional suppression, even in moments of profound distress:

In the first days, a neighbor came to our house. I was in a terrible state. She told me, ‘You are someone who prays; you should not be so agitated.’ What does that have to do with it? (P10, female, 49, lost father)

And it is not just that. We had come back from the burial – the worst day of my life – and people said, ‘You are very devout; be self-controlled.’ I truly did not know whether to be angry at them or at my own religious beliefs. (P11, male, 50, lost father)

These accounts show how religiosity can function as a standard for social judgment, leaving mourners caught between loyalty to their faith and their emotional needs. This theme demonstrates how faith, while often a source of solace, can become a mechanism of suppression when interpreted through rigid moral expectations.

3.14. Theme 5: harmful cultural clichés

Participants frequently encountered cultural idioms intended to comfort them, but which instead intensified their distress. These clichés trivialized grief or reframed it as harmful, leaving mourners feeling misunderstood and guilty.

3.15. Subtheme 5.1: distressing the deceased through excessive lamenting (kâse-ye zahr, literally ‘bowl of poison’)

Some were told that crying too much could harm the deceased, likened to offering them a ‘bowl of poison’ (kâse-ye zahr). This belief forced mourners to choose between expressing their sorrow and protecting the loved one’s soul:

In the early days after the burial, they told me: if a mother cries for her child, it becomes a ‘bowl of poison’ that the child must drink. Hearing that was so hard. (P17, female, 59, lost child)

Sometimes I go to the cemetery when no one is there, and I am alone. I remember on the first night after burial someone said, ‘If you wail for your father, it is as if you poured a bowl of poison over his head and are tormenting him.’ I felt awful about myself. (P4, female, 24, lost father)

This idiom, though culturally familiar, transformed grief into self-blame and moral conflict, complicating the grieving process.

3.16. Subtheme 5.2: belief that grief fades after burial (khâk sarde, literally cold soil)

Another common cliché was that grief would quickly subside after burial, summarized in the phrase ‘khâk sarde’ (‘the soil is cold’). Participants strongly rejected this notion as dismissive of their ongoing suffering:

In the first days, I was in a very bad state; I could not believe they had put my young brother in the ground. However, people were saying, ‘The soil is cold; you will get better soon.’ I disagree, because I am still not well and have never forgotten my brother – even the intensity of my distress has not lessened. (P7, female, 36, lost brother)

People want to help but do not know the right way. Only three days after the burial, my friend said, ‘Do not worry, the soil is cold, and you will calm down.’ I felt no one understood me. I am still not calm. (P5, female, 27, lost mother)

Instead of comfort, these clichés left mourners feeling invalidated and isolated, deepening their distress. Overall, this theme reveals how well-intentioned cultural idioms – often intended to provide guidance, restraint, or reassurance – may inadvertently silence grief when applied prescriptively, reinforcing isolation and prolonging emotional suffering.

Across all five themes, participants described how cultural beliefs, symbols, contradictions, religious expectations, and typical clichés shaped their grieving in context-dependent ways. While these frameworks can offer shared meaning and social recognition after loss, participants in this study frequently experienced them as burdensome when they became rigid standards for judging the ‘right’ way to mourn, transforming private sorrow into a prolonged and socially entangled struggle. These findings indicate that cultural frameworks may support meaning and social cohesion, but they can also constrain adaptation by imposing narrow timelines, moral judgments, or pressure to perform grief.

To provide an interpretive synthesis of these themes, we present a preliminary conceptual framework illustrating how culturally shaped meanings and social expectations may inform participants’ PGD symptom experiences in this Iranian context (see Figure 1).

Figure 1.

Conceptual map of culturally shaped grief-related meanings in Iran.

4. Discussion

This study examined how cultural frameworks in Iran shape the experience and interpretation of PGD. The findings show that grief operates not only as an emotional response but as a socially and morally regulated process. When cultural norms define acceptable timelines and behaviours after loss, they may inadvertently prolong distress. These results align with DSM-5-TR and ICD-11 frameworks, which emphasize cultural boundaries of normative grief (Killikelly & Maercker, 2018; Prigerson et al., 2021) and extend the literature by illustrating how culturally specific expectations and narratives may be clinically relevant to understanding PGD presentations.

The first theme, Causal Attributions, captured how participants and those around them sought to explain the cause of death, often drawing on moral reasoning or supernatural interpretations. These explanations reflected culturally grounded efforts to make sense of the loss. Such culturally embedded causal beliefs mirror the types of explanatory models documented in the EMIC interview framework, which similarly identifies moral, supernatural, and social reasoning as central to understanding distress across cultural settings (Weiss et al., 1992). Comparable patterns have also been observed in studies of Afghan refugees, who likewise attributed psychological distress to culturally informed moral, interpersonal, or supernatural causes (Brea Larios et al., 2022).

Participants and those around them often explained the loss in moral terms, which reinforced self-blame and isolation. Such interpretations reflect just-world beliefs (Lerner, 1980) and have been observed in other cultural contexts where misfortune is linked to moral failure (Pitman et al., 2018; Spilka et al., 1985). In the Iranian context, such judgments were described as intensifying guilt and concerns about social judgment, which may be relevant when considering distress following bereavement (Safa et al., 2024).

At the same time, some participants instead attributed the loss to supernatural causes such as magic or sorcery, locating responsibility outside themselves. Similar processes have been documented cross-culturally, where supernatural explanations serve to manage feelings of guilt and uncertainty (Stephen, 1999). Iranian ethnographic work likewise shows that post-burial rituals draw on magical reasoning to symbolically redirect misfortune (Jamshidi, 2024). In participants’ accounts, these interpretations could provide temporary coherence; however, when held rigidly, they were also described as limiting emotional flexibility and complicating adjustment.

Although meaning making is an established component of bereavement (Neimeyer, 2001), it can take distressing forms when explanations for the loss become moralized or externalized. Prior work shows that self-blame and negative cognitions are associated with greater grief symptom severity (Boelen et al., 2006b). Consistent with this, participants in the present sample described attributions that framed the death as a moral consequence, which may contribute to cycles of guilt and perceived retribution in their ongoing grief-related distress. This pattern aligns with cognitive–behavioural models of complicated grief, which propose that persistent distress is maintained by maladaptive appraisals (e.g. self-blame, negative beliefs about the self and the loss) and avoidance processes that interfere with emotional processing and re-engagement with life (Boelen et al., 2006a).

These processes can be situated within Smid’s (2020) framework of meaning attribution, which emphasizes that interpretations of loss are culturally and relationally shaped. In this study, moral judgments, supernatural idioms, and ritual obligations were described as shaping how grief was understood and evaluated, and as burdensome when perceived as rigid or socially enforced.

The second theme, cultural symbols of mourning, highlights that, for many participants, grief was described not only as a private emotion but also as a publicly legible practice shaped by visible and behavioural norms. Cross-cultural and historical literature shows that grief expressions are shaped by culturally specific expectations, rituals, and social pressures (Rosenblatt, 2019; Ward et al., 2025). Meanings attached to grief – including what is considered legitimate, sayable, or appropriate to express – are shaped by local moral vocabularies and communicative norms (Evans et al., 2017). In this sense, the present findings align with broader evidence that shared symbols can provide structure and social recognition, while also creating evaluative standards that participants may experience as constraining their emotional expression and adjustment.

For participants, wearing black was described as a near-obligatory expression of loss. It extended beyond personal attire to include digital spaces, such as maintaining black profile images on social media. These practices functioned both as signs of respect for the deceased and as social expectations – nonconformity often drew criticism or disapproval. Similar observations have been made in Ghana, where mourning attire functions less as an individual choice and more as a socially regulated marker of moral standing (Ayesu et al., 2024). Hirsch (2020) likewise traced the symbolic association of blackness in early Islam with humility and reverence before divine will, suggesting that the colour continues to carry moral weight across Muslim societies.

At the same time, the persistence of rigid black attire in Iran underscores how grief remains publicly codified within moral and communal frameworks. While such norms may strengthen collective identity and shared reverence, they can also burden mourners with the pressure to appear perpetually bereaved, emphasizing compliance over emotional recovery. Prior studies highlight that cultural symbols of mourning not only shape identity and belonging but can also suppress authentic emotional expression (Klass et al., 1996; Rosenblatt, 2008).

Beyond clothing, participants described the social imperative to look sad. This expectation to appear sad aligns with Goffman’s (1959) concept of the ‘presentation of self,’ where individuals perform socially sanctioned emotions to maintain moral order. Within this emotional script, grief becomes a performance that must be constantly managed. Scheff (1979) argued that rituals can facilitate catharsis, yet when they become overly codified, they may pressure mourners to display sadness rather than genuinely experience or process it. Similar dynamics have been documented in other collectivist contexts. Zhou et al. (2023) found that Chinese bereaved individuals often suppressed emotional expression in public while believing they should appear sorrowful among close others – a reflection of collective norms that regulate when and how grief should be shown.

Ethnographic studies of mourning rituals in Iran further support this interpretation. Khajehi and Biet (2023) described how ta‘ziyeh – ritual drama commemorating religious martyrdom – transforms private sorrow into a public enactment of collective emotion. Similarly, Saramifar (2020) observed that during Muharram lamentations among Shi‘i volunteer militants, grief is simultaneously performed and disciplined, with participants expected to embody visible sorrow. In the present study, mourners internalized these expectations, often concealing any signs of recovery out of fear of social disapproval. Such dynamics suggest that when grief becomes performative, it risks impeding emotional processing and delaying psychological adaptation.

The third theme revealed the contradictory cultural messages that shaped participants’ bereavement experiences. Several participants described being told they had mourned long enough, implying that grief should follow a fixed social timeline. Similar attitudes were documented by Safa et al. (2024), who found that Iranian mourners – especially bereaved parents – often experienced pressure to suppress their emotions and resume everyday life as a sign of endurance. Studies conducted in other cultural contexts have similarly found that mourners frequently experience interpersonal pressure to ‘move on’ prematurely, a demand that may hinder rather than facilitate emotional adjustment (Trevino et al., 2018). These dynamics reflect the impact of social constraints, where prescriptive norms limit emotional expression and may impede emotional recovery (Burke & Neimeyer, 2012; Lepore & Revenson, 2007).

Conversely, other participants were criticized for attempting to reengage with life, as though recovery signified disloyalty to the deceased. Ashiani et al. (2024) similarly noted that Iranian mourners often struggle with societal expectations to remain publicly in mourning, as if visible grief were a measure of loyalty and respect. In a similar vein, Chan et al. (2005) found comparable patterns among Chinese bereaved parents, who feared that signs of coping would be judged as emotional indifference. Together, these expectations place mourners in a double bind: ending mourning too soon invites moral criticism, yet continuing it too long implies weakness. These conflicting messages may distort the natural rhythm of adaptation to loss. Within Stroebe and Schut’s (2016) dual process model, healthy mourning depends on oscillation between loss-oriented and restoration-oriented coping. In the present findings, paradoxical cultural norms disturbed this balance, impeding emotional recovery and heightening vulnerability to PGD.

In the next theme, participants described how religious interpretations of death – both their own and those imposed by others – often intensified distress and disrupted the natural trajectory of mourning. Previous research has typically portrayed religion as a protective factor that fosters resilience and meaning making after loss (Pargament, 1997). Also, recent Iranian qualitative evidence supports this protective framing. In a grounded theory study of older adults coping with the death of a child, Safa et al. (2024) identified ‘connecting to a higher power’ as a central coping process, indicating that religious meaning-making and perceived spiritual connection may help some bereaved individuals tolerate suffering and sustain hope following loss.

In addition, emerging intervention research in Iran suggests that spirituality-informed care may have clinical utility. For example, spiritual–religious interventions have been reported to reduce complicated grief symptoms and strengthen psychological resources among bereaved participants (Mehdipour et al., 2020), and God-oriented spiritual counselling has likewise been associated with improvements in bereavement-related psychological outcomes (Panahi et al., 2022).

However, the present findings diverge from this pattern, showing that religiosity can also function as a social mechanism of control. Similarly, Gökmen and Sami (2024) found that negative religious coping – such as interpreting loss as divine punishment – intensifies psychological distress following bereavement. Consistent with this, Sharif et al. (2018) found that negative religious coping was associated with higher levels of death-related depression among Iranian patients with cancer, indicating that certain religious appraisals may intensify emotional suffering rather than alleviate it.

Several religious participants perceived the death of their loved ones as fundamentally unjust. This perception challenged their belief in a just and protective God, creating a spiritual conflict between reverence and resentment. This experience aligns with the concept of spiritual disillusionment, in which grief triggers doubt about divine fairness and disrupts meaning making (Exline et al., 2011). In the Iranian context, where questioning God may be stigmatized, such tension can heighten guilt and prolong distress, transforming faith from a source of comfort into a source of inner conflict.

Across cultural settings, recent evidence reinforces this complexity: in Turkey and broader suicide-bereavement research, rigid or conformity-oriented religiosity has been shown to amplify guilt and hinder adjustment (Köroğlu & Durat, 2025; Alexandre Silva de Almeida et al., 2025). Similar patterns have emerged in Western contexts, where spirituality may both facilitate and hinder recovery – depending on whether faith is flexible and personal or rigid and stigmatizing (Čepulienė & Skruibis, 2022). These findings suggest that religion’s role in bereavement is not inherently adaptive or maladaptive but depends on the social and cultural context in which it is practiced. In some highly moralized, collectivist settings – including aspects of the Iranian context reflected in our participants’ accounts – faith may at times shift from an internal source of comfort to an externally monitored expectation of endurance, potentially constraining emotional expression and increasing vulnerability to PGD.

Our findings also indicate that cultural clichés in Iran shape how prolonged grief is assessed, interpreted, and socially contained. Importantly, in the Iranian bereavement discourse, idioms and formulaic condolence expressions can also serve adaptive interpersonal functions by providing culturally conventional scripts for expressing sympathy, offering help, and maintaining social bonds (Morady Moghaddam, 2024). However, participants in the present study most often described these clichés as distressing when they were applied prescriptively or used to morally evaluate the ‘appropriateness’ of grief. One widely used idiom, khâk sarde (‘cold soil’), suggests that sorrow is expected to diminish after burial, which may undermine the legitimacy of continued grief. When expressions of loss extend beyond culturally prescribed timelines, mourners may face moral criticism and stigma – an experience consistent with Doka’s (2002) and Corr’s (1999) work on disenfranchised grief. These normative expectations can push bereaved individuals to hide distress, contributing to shame, self-blame, and disruptions in adaptation. Similar dynamics have been documented in research on cultural concepts of distress. Bovey et al.’s (2025) systematic review of trauma-related CCDs shows that culturally shared idioms, moral expectations, and social norms often dictate how distress should be expressed, suppressed, or morally judged. These insights closely parallel the Iranian context, where idioms and culturally sanctioned mourning timelines can shape not only the perceived legitimacy of grief but also the social and moral consequences of exceeding those boundaries.

Conversely, the idiom kâse-ye zahr (‘bowl of poison’) conveys that overt expressions of grief might harm the deceased, positioning emotional restraint as a moral obligation. Research on Iranian mourning traditions supports this dynamic, showing that grief is evaluated in relation to spiritual accountability to the deceased (Abe, 2023; Pócs, 2019). Under such beliefs, mourners suppress emotional expression to avoid being regarded as responsible for spiritual distress. With time, this suppression impedes the healthy processing of loss and increases vulnerability to persistent PGD symptoms.

Together, these two mechanisms – the temporal invalidation of grief and moralized inhibition of expression – may contribute to a social environment in which visible grief is treated as unacceptable. As noted by Martin and Doka (2000) and underscored in Wohlmann’s (2023) work on stereotypes, clichés can circulate as everyday forms of social control that shape who may grieve, and in what ways. In line with recent arguments for enhancing grief literacy (Breen et al., 2022), our results suggest that limited cultural space for ongoing grief may contribute to silence, constrain help-seeking, and normalize suffering within social norms.

Overall, these findings emphasize that PGD is not solely a clinical condition but also a cultural experience. In this study, participants described culturally salient attributions, symbols, paradoxical expectations, religious prescriptions, and everyday clichés as shaping their grief experiences and, at times, as being associated with more persistent distress.

Responding to this requires culturally attuned PGD assessment tools, such as the Prolonged Grief Disorder Cultural Supplement (Killikelly et al., 2023), as well as community-based initiatives that broaden grief literacy. These findings highlight the importance of integrating cultural meaning-making, relational expectations, and spiritual narratives into clinical assessment and intervention. Training clinicians in culturally informed grief care, alongside efforts to expand grief literacy and reduce stigma, may facilitate earlier identification and support for those at risk of PGD. Future studies should examine variation across different Iranian regions, genders, and types of loss, and evaluate culturally adapted PGD interventions in real-world clinical settings.

4.1. Strengths and limitations

A key strength of this study lies in its focus on PGD within an underrepresented cultural context, yielding insights relevant to both clinical practice and global conceptualizations of PGD. Additionally, the use of thematic analysis allowed for the systematic interpretation of lived experiences in relation to diagnostic criteria. However, the findings reflect a relatively small, urban sample from Tehran, which may limit transferability to other regions or cultural groups within Iran. As with all qualitative studies, results are shaped by participants’ accounts and the researcher's interpretation; nonetheless, reflexivity and analytic transparency were employed to enhance credibility. Future research should incorporate larger, more diverse samples and longitudinal or comparative approaches to better identify culturally specific influences on PGD and to inform tailored interventions.

5. Conclusion

This study shows that PGD in Iran is influenced by cultural beliefs and moral expectations surrounding mourning. Participants described experiences of guilt, limited emotional expression, and heightened concerns about stigma. By identifying these dynamics, the study offers a more culturally grounded understanding of PGD and highlights the importance of culturally responsive assessment and intervention. Comprehensive care may benefit from combining clinical support with community-based initiatives that reduce social pressures while preserving the supportive elements of mourning traditions.

Appendix A. Semi-Structured Interview Guide

Opening & Rapport Building

1. To begin, could you please tell me a little about yourself and your relationship with the person you lost? How long has it been since the loss happened?

Core interview questions

2. Regarding the problem you're dealing with, what upsets you the most about it?

3. Since the loss, what thoughts or feelings have occupied your mind the most?

4. How has your grief changed over time?

5. What do other people in your family, your friends, or others in your social network think about your problem?

6. How did people around you respond to the way you were grieving?

7. Has anything prevented you from getting the help you needed?

8. In your culture or community, what beliefs, expectations, or norms exist about how someone should grieve?

9. Were there symbolic practices (such as clothing, rituals, mourning customs) that influenced your grieving process?

10. Did you ever feel pressure to grieve in a certain way because of others’ expectations or judgments?

11. Are there any cultural or religious sayings, phrases, or rituals that affected how you felt or behaved during mourning

12. Have you ever felt pressure to appear sadder, or less sad, because of cultural or religious expectations?

13. Looking back, what has helped you the most  – or made things harder  – in your grieving process?

Probing prompts (used as needed)

- Can you tell me more about that?

- How did that affect you?

- What do you mean by … ?

- Can you give an example?

Closing question

14. Is there anything else about your grieving experience or cultural beliefs that you think is important and we haven’t talked about yet?

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval

The study was approved by the Ethics Committee of Shahid Beheshti University (Approval ID: IR.SBU.REC.1403.123) and conducted in accordance with the Helsinki Declaration.

Data availability statement

The qualitative interview transcripts are not publicly available because they contain sensitive information, and full anonymization cannot be guaranteed. All participants are de-identified in the manuscript and only non-identifiable excerpts are reported. Data may be made available on reasonable request to the corresponding author, subject to ethical approval.