Grief and bereavement

Key messages

Definition and prevalence

Grief is a natural response to loss, encompassing a range of emotional, physical, spiritual and cognitive reactions. In the context of bereavement, grief occurs in response to the death of a significant person. Grief can also begin before a death has occurred, with ‘pre-death grief’ arising in response to uncertain or poor health prognosis and associated changes in family roles, communication, and carer burdens. [1] While grief can be intense and destabilising, the majority of people are able to adapt to their loss with grief symptoms improving over time.

For some people, grief remains persistent and continues to impact functioning beyond the first 6-12 months. This has been identified as PGD, replacing earlier terminology of complicated grief. The prevalence of grief disorder varies significantly. PGD affects about 10% of bereaved individuals, with higher rates observed among those who had close emotional bonds with the deceased or those who provided direct care. [1,2] PGD is also more prevalent in populations experiencing sudden or unexpected losses and in caregivers of people with dementia or terminal illnesses. [3,4] PGD indicates a need for clinical intervention. [4,5]

Assessment

Assessment of grief and bereavement ought to be a comprehensive process, whereby health providers engage in an ongoing process of assessment and screening with an emphasis on cultural sensitivity. Tools such as the Inventory of Complicated Grief (ICG), Prolonged Grief Disorder (PG13) and the Grief Experience Questionnaire (GEQ) may be used to measure the severity of grief and its multidimensional impacts, however further research is indicated. [4,5]

Healthcare providers, including general practitioners (GPs) and multidisciplinary palliative care teams, play an important role in the initial screening and ongoing assessment of grief. [1,5] GPs often serve as the first point of contact, conducting initial assessments and referring patients to mental health specialists when necessary. [5] Palliative care teams ought to adopt a holistic approach, addressing the emotional, social and spiritual needs of patients and their families, and aim for comprehensive support throughout the grieving process. [6,7]

Cultural sensitivity is paramount in the assessment process, given Australia's diverse population. [8,9] Different cultural groups have unique expressions of grief and healthcare providers must be trained to recognise and respect these differences. [8,9] Culturally adapted assessment tools and practices, such as involving community leaders and using interpreters, are essential for providing equitable care. [8,9]

Non-pharmacological treatment

Non-pharmacological treatments for grief and bereavement encompass a range of therapeutic interventions aimed at addressing the emotional and psychological aspects of grief. Grief therapy is most effective for individuals who are experiencing complications in their grief, and for people who self-refer. [10] For many people, grief does not require specialist intervention as it is commonly an intrapsychic and interpersonal experience of adjusting to and making sense of the loss. [11] This makes it challenging to assess the efficacy of grief therapies. However, approaches incorporating CBT, acceptance and commitment therapy, meaning reconstruction, trauma-focused and narrative modalities have shown benefit. [11]

CBT is a widely recognised approach that helps individuals reframe negative thoughts and develop healthier coping mechanisms. [1,12] CBT has been shown to be effective in reducing symptoms of PGD and CG by encouraging individuals to confront and process their emotions. [1,12] Techniques such as cognitive restructuring and exposure therapy within CBT frameworks enable individuals to face painful memories and reduce avoidance behaviours. [13] Further evidence is required to determine the overall efficacy of CBT in reducing grief symptoms. [11] ACT is another effective non-pharmacological approach. ACT focuses on helping individuals accept their grief and commit to actions that align with their values, despite the presence of difficult emotions. [12,14] Studies have shown that ACT can reduce psychological distress and improve the overall quality of life by promoting emotional acceptance and mindfulness. [12,14] ACT has been particularly beneficial for bereaved spouses and caregivers, as it facilitates the acceptance of loss and reduces symptoms of anxiety and depression. [12]

Support groups and bereavement counselling are also vital components of non-pharmacological treatment. These interventions provide a communal space for individuals to share their experiences and receive emotional support. [5,15] Group settings foster a sense of belonging and reduce feelings of isolation, which are common in grief. [5,15] Music therapy has also been identified as a beneficial intervention, particularly in pre- and post-bereavement phases, helping to alleviate grief symptoms and provide comfort through creative expression. [16]

Pharmacological treatment

Pharmacological treatments for grief and bereavement typically involve medications to manage severe symptoms that interfere with daily functioning. [1] Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed to individuals experiencing significant depression or anxiety due to grief. [1,12] These medications help stabilise mood and reduce emotional distress, making it easier for individuals to engage in therapeutic activities. [1] SSRIs such as fluoxetine and sertraline have shown efficacy in alleviating symptoms of PGD, reducing both depressive and anxiety symptoms associated with grief. [1]

Benzodiazepines, including medications like diazepam and lorazepam, may be used on a short-term basis to manage acute anxiety and insomnia in grieving individuals. [17] These medications can provide immediate relief from severe symptoms, allowing individuals to participate more fully in non-pharmacological therapies. [17] However, their use is generally limited due to the risk of dependency and adverse side effects, such as cognitive impairment and increased risk of falls, particularly in older adults. [17] The long-term use of benzodiazepines is discouraged, and they are typically prescribed only for short-term relief during particularly acute phases of grief. [17]

Emerging research also supports the use of medications targeting specific symptoms associated with grief, such as prazosin for trauma-related nightmares and sleep disturbances. [17] Additionally, there is growing interest in the potential of MDMA-assisted psychotherapy to enhance emotional processing and reduce the intensity of grief symptoms. [1] These innovative approaches represent the evolving landscape of pharmacological interventions in grief and bereavement care, highlighting the need for ongoing research to optimise treatment efficacy and safety. [1,17]

Equity and access

Grief and bereavement services often fall short in Australia due to insufficient funding and resources. [5] Culturally and Linguistically Diverse (CALD) populations face significant barriers, including lack of awareness, cultural insensitivity, limited support in languages other than English and variability in the support offered. Insufficient training for healthcare professionals on culturally competent care exacerbates these issues, as services are frequently not tailored to meet the specific needs of these communities. [18] Cultural humility is an approach where healthcare practitioners can acknowledge their own cultural biases and engage in continuous self-reflection and learning to understand and respect the cultural perspectives of their patients. [19] Unlike cultural competence, which implies a mastery of cultural knowledge, cultural humility emphasises an ongoing process of learning and adapting. [19] To better serve CALD communities through grief and bereavement, professionals can prepare to accommodate various cultural rituals and practices related to death and mourning, which may include providing space for specific mourning rituals, understanding different grieving timelines and being sensitive to the ways families communicate about and cope with death. [19] Healthcare professionals ought to be aware that cultural taboos and preferences can significantly impact how patients and families experience and express grief, and they should strive to honour these preferences whenever possible. [19]

In the context of homelessness, grief is compounded by the lack of stable housing and social support networks. Service providers working with homeless populations often lack training in bereavement care, and the transient nature of homelessness makes consistent support challenging. [20] Trauma-informed care is essential in this context, as individuals experiencing homelessness are more likely to have multiple traumatic experiences that complicate their grief. Integrating grief counselling into housing services and providing staff training on death and bereavement can help address these needs. [20]

Rural populations face unique challenges due to geographic isolation and limited access to specialised services. Telehealth has emerged as an important tool in providing grief support to these communities, offering remote access to counselling and support groups. [6] However, technological barriers, such as lack of internet access and digital literacy, can impede the effectiveness of telehealth services. Ensuring that rural healthcare providers are trained in grief assessment and intervention, and that they are equipped with the necessary technology, is vital for improving access to bereavement care in these regions. [6,18]

Care context

Grief and bereavement care must be tailored to suit various settings and populations, each presenting unique needs and challenges. In paediatric settings, children and adolescents require specialised interventions to address their developmental stages and cognitive abilities. Grief in younger populations is often expressed through behavioural changes, academic difficulties and physical symptoms, rather than verbal articulation of emotions. [21] Effective strategies include play therapy, art therapy, and family counselling, which provide safe spaces for children to express their feelings and process their loss. [22] Additionally, involving schools in the bereavement support plan can ensure that children receive consistent support across different environments. [21]

In aged care settings, the experience of grief can be compounded by the presence of multiple losses, including the death of peers, loss of independence and declining health. Older adults may also face social isolation, which can exacerbate feelings of grief and loneliness. [17] Interventions in these settings often include grief counselling, support groups, and activities that promote social engagement. Training aged care staff in recognising and responding to signs of grief is essential, as is creating an environment where residents feel comfortable discussing their emotions. [7,17] Palliative care teams in aged care facilities can play an important role by integrating grief support into their holistic care approach, ensuring that emotional and psychological needs are addressed alongside physical health. [3]

Individuals grieving non-cancer conditions, such as those with dementia, face specific challenges that differ from those grieving cancer-related deaths. Dementia-related grief is often prolonged and complex due to the gradual nature of the disease and the ongoing anticipatory grief and pre-death losses experienced by caregivers. [3] Caregivers may struggle with feelings of guilt, anger and helplessness as they witness the cognitive and physical decline of their loved ones. [23] Support for these caregivers includes providing information about the disease, offering respite care, and facilitating support groups where they can share experiences and strategies for coping. [23] Health and social care services ought to collaborate to ensure that caregivers receive continuous support throughout the disease trajectory, and after the death of their loved one. [23]