Bereavement and Grief

Key messages

  • Expressions of grief can vary widely from person to person
  • Most people who experience normal grief do not require specialist counselling, but would benefit from reassurance, acknowledgement of their losses, and access to information
  • A proportion of people who grieve may experience intense distress over a prolonged period
  • A number of options for referral for bereavement difficulties exist:
    • Specialist bereavement counsellors
    • Palliative care services usually offer bereavement follow up to their clients, often based on bereavement risk assessment, and may also sometimes accept referrals from other sources
    • Other mental health professionals with appropriate skills and expertise.

Overview

Bereavement refers to the event of death of a person with whom there has been an enduring relationship.

Grief is how bereavement affects us personally, with effects across several domains – emotional, cognitive, social, physical, financial and spiritual. Grief often causes disruption and disturbance of everyday life. However, grief can be expressed in very different ways: some people do not experience an intense reaction. Most people experience fluctuating reactions for a period of time while others can develop an intense and prolonged grief response. [1,2] Culture plays a major role in the expression of grief. [3]

Common expressions of grief are varied and can include: [4]

Emotional

  • Depression
  • Anxiety
  • Guilt
  • Anger
  • Loneliness
  • Loss of pleasure
  • Shock and numbness.

Cognitive

  • Thinking all the time about the person who has died
  • A sense that the dead person is still about
  • Denial
  • Hopelessness.

Behavioural

  • Over or under activity
  • Social withdrawal
  • Agitation.

Physical feelings

  • Loss of appetite
  • Sleep disturbances
  • Tiredness.

Physiological

  • Susceptibility to illness.

What is known

For most people, grief is accommodated over time with support of family and friends. [5] Identifying the fact that there may also be positive outcomes of bereavement, including the potential for post-traumatic growth, is a recent development within the field; [6] 'resilience' is one of the key concepts that is being used to understand and acknowledge the way that people deal with their grief and bereavement. [7]

There is no evidence that sharing and disclosure of feelings will lead to ‘healthy’ or less intense grieving for those people who experience normal grief reactions. [4] There is also no evidence that grief counselling improves outcomes for people who experience normal grief. [8-10]

Protective factors in the health outcomes of bereavement may include: [4]

  • Responsive health care for the dying patient and reduction of patient distress before death
  • Optimistic and resilient personality characteristics of bereaved individuals
  • Secure relationships with family and community.

Common patterns of response to spousal bereavement have been identified. Spousal loss occurs most frequently in later life, more often affects women, and for many bereaved spouses, it interacts with and compounds other health concerns. Maintaining independence is a common challenge in this situation for older people. [11]

Bereavement is a period of increased mortality for spouses. A meta-analysis has confirmed that men who are widowed are particularly at risk, and the first six months is the highest risk period. [12] The risk is associated with both expected and unexpected deaths, but social support may reduce the risk. Patient end-of-life interventions may positively influence bereavement outcomes for spouses. [13] The increased risk is unrelated to the age of the bereaved person. Cardiovascular risk for the spouse who survives is increased, particularly in the first few weeks. [14] The vulnerability may be due to both the physiological impacts of grief, and also to altered health behaviours. There is evidence that in late-life spousal loss health behaviour changes can affect sleep, alcohol use, and nutritional intake causing involuntary weight loss. [15]

Bereavement in childhood is common. About 5% of children will lose a parent or sibling, and up to 75% will experience the loss of a relative or friend before the age of 16. [16] Most often this is associated with short term negative impact, but few longterm difficulties.

The impact of caregiving on grief and bereavement is being studied. High levels of social and emotional support can modify bereavement distress, and there is some evidence that receiving support from palliative care services, and home deaths, may improve bereavement outcomes for caregivers. [17]

Active research areas / controversies

  • There is a trend in research which is critical of stage-based models of grief that suggest bereaved people ‘move on’ from their grief and relinquish the bond or connection to the dead person. [4,18]
  • Research suggests that normal grief differs from abnormal grief in a variety of ways, and that abnormal grief is distinct from other psychiatric diagnoses such as depression, anxiety and PTSD. Associated assessment tools and new treatment strategies are evolving based on improved understandings of these phenomena. [18,19]
  • Research is needed into the personal profile of those at risk of abnormal grief, including psychological characteristics and interpersonal factors, such as their perception of social and community supports. [3,5] Issues of screening, referral and how to match intervention to the individual require further research.
  • Specific grief considerations for different groups such as parents, [9,21,22] fathers, [23] children, [24] spouses, [25] those from different cultural backgrounds, [3] in the setting of perinatal loss, [26] and in indigenous populations, need further investigation.
  • Research into the efficacy of bereavement interventions needs attention.  While specific bereavement interventions appear to assist those people experiencing abnormal grief, more detail is needed. Cost effectiveness of bereavement services has not been well studied. [27]
  • Little is known about how and to what extent bereaved people are cared for in primary care, nor the impact of that care. [28]
  • The grief experiences of health care providers have not been well-studied, but these may have significant impact on health service delivery, and result in both emotional and economic costs to the system. [29]
  

PubMed Searches

  1. Christ GH, Bonanno G, Malkinson R, Rubin S. Bereavement experiences after the death of a child. In: Field MJ, Behrman RE, editors. When children die: improving palliative care and end-of-life care for children and their families. Washington, DC: The National Academy Press; 2003.
  2. Wortman CB, Cohen Silver R. The myths of coping with loss revisited. In: Stroebe MS, Hansson RO, Stroebe W. Schut H.Hanbook of bereavement research: consequences, coping and care. Washington, DC: American Psychological Association; 2001.
  3. Wimpenny P, Unwin R, Dempster P, Grundy MA, Work F, Brown A. Literature review on bereavement and bereavement care. Joanna Briggs Collaborating Centre for Evidence-based Multi-professional Practice. Aberdeen: Robert Gordon University; 2006.
  4. Stroebe M. Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007 Dec 8;370(9603):1960-73.
  5. Agnew A, Manktelow R, Taylor B, Jones L. Bereavement needs assessment in specialist palliative care: a review of the literature. Palliat Med. 2010 Jan;24(1):46-59. Epub 2009 Sep17.
  6. Michael C, Cooper M. Post-traumatic growth following bereavement: A systematic review of the literature. Counsell Psychol Rev. 2013 Dec;28(4):18-33. (No abstract available)
  7. Holm AL, Severinsson E. Systematic review of the emotional state and self-management of widows. Nurs Health Sci. 2012 Mar;14(1):109-20. Epub 2012 Jan 30. 
  8. Jordan JR, Neimeyer RA. Does grief counselling work? Death Stud. 2003 Nov;27(9):765-86.
  9. Currier JM, Neimeyer RA, Berman JS. Effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive qualitative review. Psychol Bull. 2008 Sep;134(5):648-61.
  10. Schut H, Stroebe MS. Interventions to enhance adaptation to bereavement. J Palliat Med. 2005;8 Suppl 1:S140-7.
  11. Naef R, Ward R, Mahrer-Imhof R, Grande G. Characteristics of the bereavement experience of older persons after spousal loss: an integrative review. Int J Nurs Stud, 2013 Aug;50(8):1108-21. Epub 2012 Dec 28.
  12. Moon JR, Kondo N, Glymour MM, Subramanian SV. Widowhood and mortality: a meta-analysis. PLoS One. 2011;6(8):e23465. Epub 2011 Aug 17.
  13. Gauthier LR, Gagliese L. Bereavement interventions, end-of-life cancer care, and spousal well-being: A systematic review.Clin Psychol Sci Pract. 2012 Mar;19(1):72-92.
  14. Buckley T, McKinley S, Tofler G, Bartrop R. Cardiovascular risk in early bereavement: a literature review and proposed mechanisms. Int J Nurs Stud. 2010 Feb;47(2):229-38. Epub 2009 Aug 8.
  15. Stahl ST, Schulz R. Changes in routine health behaviors following late-life bereavement: a systematic review. J Behav Med. 2014;37(4):736-55. Epub 2013 Jul 24.
  16. Akerman R, Statham J. Childhood bereavement: a rapid literature review. Loughborough (UK); Childhood Wellbeing Research Centre: 2011 Sep.
  17. Remedios C, Thomas K, Hudson P. Psychosocial and bereavement support for family caregivers of palliative care patients: A review of the empirical literature. Melbourne: Centre for Palliative Care; 2011 Jan. 71p. (896kb pdf)
  18. Neimeyer RA. The changing face of grief: Contemporary directions in theory, research, and practice.Progr Palliat Care. 2014;22(3):125-30.
  19. Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011 Feb;28(2):103-17.
  20. Hendrickson KC. Morbidity, mortality and parental grief: A review of the literature on the relationship between the death of a child and the subsequent health of parents. Palliat Support Care. 2009 Mar;7(1):109-19.
  21. Rosenberg AR, Baker KS, Syrjala K, Wolfe J. Systematic review of psychosocial morbidities among bereaved parents of children with cancer. Pediatr Blood Cancer. 2012 Apr;58(4):503-12.
  22. Ungureanu I, Sandberg JG. “Broken Together”: spirituality and religion as coping strategies for couples dealing with the death of a child: A literature review with clinical implications. Contemp Fam Ther. 2010 Sep;32(3):302-19. First online: 
  23. Aho AL, Astedt-Kurki P, Tarkka MT, Kaunonen M. Development and implementation of a bereavement follow-up intervention for grieving fathers: an action research. J Clin Nurs. 2011 Feb;20(3-4):408-19. Epub 2010 Oct 14.
  24. Currier JM, Holland JM, Neimeyer RA. The Effectiveness of Bereavement Interventions with children: a meta-analytic review of controlled outcome research. J Clin Child Adolesc Psychol. 2007 Apr-Jun;36(2):253-9.
  25. Fasse L, Sultan S, Flahault C, Mackinnon CJ, Dolbeault S, Bredart A. How do researchers conceive of spousal grief after cancer? A systematic review of models used by researchers to study spousal grief in the cancer context. Psychooncology. 2014 Feb;23(2):131-42. Epub 2013 Sep 30.
  26. Fenstermacher K, Hupcey JE. Perinatal bereavement: a principle-based concept analysis. J Adv Nurs. 2013 Nov;69(11):2389-400. Epub 2013 Mar 4.
  27. Arthur A, Wilson E, James M, Stanton W, Seymour J, University of Nottingham. Bereavement care services: a synthesis of the literature. London: Department of Health; 2011 Jan. 73p.
  28. Nagraj S, Barclay S. Bereavement care in primary care: a systematic literature review and narrative synthesis. Br J Gen Pract. 2011 Jan;61(582):e42-48.
  29. Genevro JL, Miller TL. The emotional and economic costs of bereavement in health care settings. Psychologica Belgica. 2010;50(1-2):69-88. 
Last updated 17 January 2017