Bereavement is the experience of having lost someone close who has died. Grief is the biopsychosocial response to bereavement and can include a range of feelings such as anger, denial, relief, guilt and sadness. Everyone will experience grief in their lifetime. For some people the acute pain of grief will continue and stay for a long period, for others it will fade, allowing the bereaved person to accept their loss.
The Covid-19 pandemic has brought into sharp focus the importance of a structured range of bereavement and anticipatory grief support incorporating community, organisational and specialist responses.
Impact of grief
Grief is not time-limited and will vary between individuals and cultures and will be affected by the relationship to the person who has died and the circumstances of the death. Grief is not a linear process and there is no standard emotional response when suffering from bereavement.
Common issues to be addressed include loneliness, extreme isolation and a sense of not being understood in their grief.
People of any age can suffer from grief and it should not be assumed that bereaved older people require less support than those bereaved at a younger age. Intense loneliness can come from a bereavement and lead to increased isolation and in time, chronic loneliness. This is more likely for the older population as they are more likely to experience a bereavement.
Complicated grief occurs when, despite passage of time or support received, a person is unable to emotionally recover from their loss. Attributes of complicated grief include preoccupying thoughts of the person who has died, distressing thoughts related to death, avoidance of reminders, intense yearning for the deceased and loss of interest in life.
Risk factors for complicated grief include the bereaved person’s previous experiences and mental health as well as the nature of the death. Sudden and unexpected death such as those from suicide, violence or the loss of a child or partner are believed to increase likelihood of complicated grief.
It is estimated that 7% of bereaved people experience complicated grief. Evidence suggests that it may be possible to identify signs of complicated grief from six months onwards.1
For people who are known to be at risk of complicated grief it is important that a range of early intervention is available and that further support and access to counselling, psychotherapy or other forms of 1-1 support is offered if symptoms persist. Counselling and psychotherapy may also be appropriate where grief or loss is an additional presenting issue.
Complicated grief should be recognised as being distinct from ‘normal’ or ‘integrated’ grief, which is fluid and adaptive, allowing people to continue with life despite their sadness.
Comprehensive model of support
Quality bereavement support includes access to suitable immediate advice and assistance, peer support, group support and online support as well as also structured support such as 1-2-1 counselling and psychotherapy or group therapy.
People and organisations have different needs in dealing with bereavement including:
- psychoeducation for employers, organisations and individuals
- skilled support from peers/trained and experienced supporters in paid and voluntary roles
- counselling and psychotherapy (1-2-1 or in a group)
This range of support can be made available through a three-tiered community response model which recognises and responds to all who are bereaved:
Tier 1 delivers supportive responses from existing community networks such as places of worship, neighbourhoods, clubs and societies and offers help and support including peer support and signposting to other services. This should be available for all bereaved people.
Tier 2 combines the community responses with professional support such as a bereavement support organisation. This will be accessed by some bereaved people.
Tier 3 provides specialist psychological 1 to 1 or group support which may include counselling or psychotherapy. This will be required by a smaller proportion of bereaved people.
Bereavement and Covid-19
With the onset of the Covid-19 crisis and the lockdown restrictions, people have been bereaved in complex circumstances. Absence of opportunities to be close to those who have died, denial of the usual rituals and customs of funerals and multiple sudden deaths in hospitals and care homes, have all contributed to people being bereaved in shocking and sudden ways.
Grief following a coronavirus related death may result in a more traumatic bereavement and in some cases result in post-traumatic stress disorder (PTSD).
The implementation of trauma-informed principles (keeping people safe, restoring choice and control, supporting ability to cope, facilitating connections with others, responding to the ways people identify themselves and building resilience) provides a framework for bereavement support that responds to the needs of people bereaved during the pandemic.
The unique context of bereavement during a global pandemic has the potential for an amplification of distress, which needs to be considered by those providing support. In some circumstances a response associated with dealing with traumatic events may be needed, including early intervention with additional structured support later, if required.
The three-tiered model of bereavement support is evident in the Covid-19 Bereavement and Loss Support service delivered by a collaborative of counselling organisations in Bradford.
The service, commissioned by NHS Bradford District and Craven CCG, provides an all-age community-based response to people bereaved by or during the Covid-19 pandemic and includes access to support in a range of community languages.
Calls to the service phone line are received directly from bereaved people or from frontline workers in contact with those experiencing loss. Initial telephone response is brief and matches presenting need with local or national support organisations. Callers requiring immediate help are introduced to bereavement support volunteers recruited and trained within the service.
Bereavement support volunteers provide help on a range of emotional, practical and immediate needs such as funeral arrangements and navigation of services and support that is needed. For older people experiencing isolation or loneliness the volunteer’s role can be as a befriender.
When the bereaved person’s need goes beyond that which can be met by either the phone line or bereavement support volunteer, referral is made for immediate contact with a trained and qualified bereavement counsellor providing six to eight sessions of telephone or video conference counselling, with further referral to specialist mental health services such as IAPT on completion, if required.
The service has been designed to deliver an immediate response to bereavement needs, using a systematic approach that draws on existing community resource in partnership with statutory, voluntary and community organisations and that recognises and responds to the particular need emerging from the Covid-19 crisis.
The Covid-19 pandemic highlights an acute need for early community-led responses to sudden bereavement within a tiered model which recognises need, responds in ways that keep people safe and meet practical as well as emotional needs, and can refer on to specialist services when these are required.
BACP, Cruse and other organisations are calling on all UK governments to recognise the psychological impact of the Covid-19 crisis and to ensure that additional mental health needs are met.
Accessible national and local psychosocial services are required to enable access to a community response to bereavement:
- it is recommended that information is readily available online for bereaved people and community providers of care and support
- referral to community support providers should be open and readily available, with choice offered to the bereaved persons
- support must take account of practical as well as emotional needs and promote self-determination and control for the bereaved person
- a small proportion of bereaved people will have long term problems that require ongoing support. Bereavement support services must be responsive to this longer term need and include availability of structured 1 to 1 or group support, counselling or psychotherapy, and referral to mental health services for people requiring specialist intervention.
BACP and Cruse
Cruse Bereavement Support is the leading national charity offering support, advice and information to bereaved people in England, Wales and Northern Ireland. To improve access to the best possible bereavement support for people when they’ve experienced the loss of someone close, BACP and Cruse have established a strategic partnership.
Our organisations believe that all bereaved people should have access to a choice of support and reassurance to help them to deal with their grief and that where helpful, bereaved people should have access to expert guidance to identify the support most suited to their needs.
1 Kersting A, Brähler E, Glaesmer H, Wagner B. Prevalence of complicated grief in a representative population-based sample. J Affect Disord. 2011;131(1-3):339-343. doi:10.1016/j.jad.2010.11.032
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