Does grief counseling work?

Evaluating the Effect of Participation in Bereavement Support Groups on Perceived Mental Well-Being and Grief Reactions

The study aimed to evaluate the effect of participating in bereavement support groups on mental well-being and levels of grief and to gather information about participants´ experiences of participation. The programme consisted of six sessions over six weeks. Data were collected with the Warwick Edinburgh Mental Well-Being Scale (WEMWBS) and the Adult Attitude to Grief scale (AAG) as well as demographic and open-ended questions. 64 bereaved spouses returned at least parts of the study´s questionnaires before participating in the programme while 39 returned the complete WEMWBS and 36 the complete AAG both before and after participation. Most participants were women >60 years old. Participation in the programme resulted in a significant increase in perceived mental well-being and significantly lower levels of vulnerability in grief. Responses to open-ended questions revealed both positive and negative experiences. A lowered WEMWBS score and a relatively high AAG underscore the importance of providing services to the recently bereaved. Routine screening for complicated grief before participating in the bereavement support group sessions is recommended.

Comparing Public Perceptions of Child and Adult Grief Responses to Familial Incarceration

Children of incarcerated parents may grieve this loss, yet perceptions of their grief are understudied. Using vignettes varying by age (adult/child) and grief response (prolonged/resilient), we examined differences between perceptions of adults and children grieving parental incarceration. Participants rated grief response appropriateness, comfort providing support, and grief therapy recommendations for the grieving person in the vignette. Participants perceived resilience as more appropriate than prolonged grief [F (1, 224) = 9.02, p = .003, η2 = .04]. Age did not predict outcomes. Recommending grief therapy was higher for prolonged grief, yet 53% of participants with resilient vignettes recommended the person should seek grief therapy, which is concerning given possible iatrogenic effects. Thus, laypeople may have stigma toward individuals grieving parental incarceration, regardless of age.

Grief and bereavement beliefs and their associations with death anxiety and complicated grief in a U.S. college student sample

This study examined beliefs about grief and bereavement, and how the endorsement of myths is related to death anxiety and complicated grief. Results from a sample of college students in the United States (N = 391) suggested that myths about grief and bereavement are prevalent in this group. Additionally, the endorsement of certain myths significantly explained both death anxiety and complicated grief. Findings from this study provide additional support for death education in college and university settings to promote grief literacy. Implications for education, advocacy, research, and practice are discussed.

How do enrollees feel about support in Big Hospices? - The caregiver experience of emotional, spiritual, and bereavement support by profit status among large US providers

OBJECTIVES

Recent findings narrate profiteering detrimentally impacting hospice care quality. However, no study has examined the caregiver experience of emotional and spiritual support expressed online. The purpose was to evaluate the hospice caregiver's experience of emotional, spiritual, and bereavement support and whether the care was respectful and compassionate to the care unit.

METHODS

Retrospective mixed methods of sentiment and quantitative analysis. Sources were online caregiver reviews (n = 4,279), Consumer Assessment of Healthcare Providers and Systems (CAHPS) data on the 50 largest US hospices.

RESULTS

Caring and compassionate professionals were lauded in nonprofit (+.57) and for-profit settings (+.46). The nonprofit experience was in the excellent range (+42) for emotional, spiritual, and bereavement support but fell to dissatisfying (-.15) among for-profits. A respectful experience (16%) was much less commonly expressed than a compassionate one (38%). Distribution of CAHPS "Treating patient with respect" (M = 89.62, SD = 2.63) and "Emotional and spiritual support" (M = 89.80, SD = 2.04) limited inter-hospice comparisons.

SIGNIFICANCE OF RESULTS

Compassionate professionals were thanked and praised regardless of profit status. Sadly, anger was expressed toward large, for-profits more fixated on census than emotional, spiritual, and bereavement support; thankfully nonprofits were more supportive. CAHPS items for "Treating patient with respect" and "Emotional, spiritual support" offer limited discriminating value since low CAHPS performers always had relatively high scores on these 2, yet otherwise low scores on the remaining 6. Online reviews on the same topics provide a more substantive and realistic appraisal - distinguishing high from low performers. A higher bar than mere respect is needed for the tender experience of death, dying, and grieving. Compassion is an especially relevant addition to CAHPS since caregivers named compassionate staff as a distinguishing factor. Parity for mental health at end of life is a vital research topic. Future research should also explore the caregiver expectations set on admission.

Developing a best-practice agenda for music therapy research to support informal carers of terminally ill patients pre- and post-death bereavement: a world café approach

BACKGROUND

Informal carers of terminally ill patients play a vital role in providing palliative care at home, which impacts on their pre- and post-death bereavement experience and presents an up to 50% greater risk for mental-health problems. However, developing and implementing effective bereavement support remains challenging. There is a need to build the evidence base for music therapy as a potentially promising bereavement support for this vulnerable population. This study aimed to co-design an international best practice agenda for research into music therapy for informal carers of patients pre- and post-death bereavement.

METHODS

Online half day workshop using a World Café approach; an innovative method for harnessing group intelligence within a group of international expert stakeholders (music therapy clinicians and academics with experience of music therapy with informal carers at end-of-life). Demographics, experience, key priorities and methodological challenges were gathered during a pre-workshop survey to inform workshop discussions. The online workshop involved four rounds of rotating, 25-minute, small group parallel discussions using Padlet. One final large group discussion involved a consensus building activity. All data were analysed thematically to identify patterns to inform priorities and recommendations.

RESULTS

Twenty-two consented and completed the pre-event survey (response rate 44%), from countries representing 10 different time zones. Sixteen participated in the workshop and developed the following best practice agenda. The effectiveness of music therapy in supporting informal carers across the bereavement continuum should be prioritised. This should be done using a mixed methods design to draw on the strengths of different methodological approaches to building the evidence base. It should involve service users throughout and should use a core outcome set to guide the choice of clinically important bereavement outcome measures in efficacy/effectiveness research.

CONCLUSIONS

Findings should inform future pre- and post-death bereavement support research for informal caregivers of terminally ill patients. This is an important step in building the evidence base for commissioners and service providers on how to incorporate more innovative approaches in palliative care bereavement services.

Improving bereavement outcomes in Zimbabwe: results of a feasibility cluster trial of the 9-cell bereavement tool

CONTEXT

Despite high mortality rates from both communicable and non-communicable diseases, bereavement is under-researched in African countries. The 9-cell bereavement tool was designed to assist individuals to reflect on their feelings about bereavement and identify resources in families and communities to manage bereavement. This study aimed to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

METHODS

A feasibility cluster randomized trial with embedded qualitative interviews was conducted in two comparable neighbourhoods in Chitungwiza, Zimbabwe. Community leaders identified potential community lay bereavement supporters (interventionists). Each community lay bereavement supporter recruited two to three recently bereaved community members (trial participants). Following baseline data collection, the communities were randomly allocated to intervention or wait-list control. Self-administered questionnaires were completed at T0 (month 0), T1 (3 months) and T2 (6 months). Grief, mental health and social support were assessed. Focus group discussions with selected interventionists described training impact and intervention processes. Quantitative and qualitative analyses were performed.

RESULTS

Implementation of the nine-cell bereavement tool and recruitment to experimental evaluation were successful. Implementation of the tool and the recruitment of study participants were conducted within the intended timeframe of 3 weeks. In line with the suggested sample size, the study was able to recruit and retain at least 75% of the trial participants for the total duration of the study.

CONCLUSION

The feasibility cluster trial was successfully implemented and assessed. Through the published protocol, the literature review and the results of this study, it has been noted that there is an urgent need to carry out a full trial in this subject matter, not only as a contribution to the currently sparse literature in this regard, but for the enormous potential public health benefit in supporting and saving lives in many more under-resourced and under-supported countries.

TRIAL REGISTRATION

Protocol registration: http://www.isrctn.com/ISRCTN16484746 . Protocol publication: https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-019-0450-5.

Markers in Time: Expanding Our Concept of Trauma Triggers to Include Subjective Experiences of Time Among Adults Surviving Traumatic Loss

We outline two studies that collected exploratory data on the meaningful time approach and explore the notion of temporal triggers that emerge in the process of coping with traumatic loss. Qualitative data analysis was completed on data gathered from face-to-face interviews as well as open ended responses to an online survey. 35 themes and sub-codes were identified. 30 of these were replicated in both studies. Our data supported the notion of "markers in time" and identified three clear phases to these markers. Participants also noted the consequences of loss on their lives, and the influence of societal and religious approaches to bereavement on their process of coping. Results of this study support a cyclical approach to understanding coping with loss and provides clinicians working with bereaved individuals yet another tool to address the dynamic experience of bereavement.

Perceptions of grief reactions in family members of incarcerated individuals: A vignette-based experiment

We examined perceptions of individuals grieving the loss of a family member to incarceration. Participants (N = 1095) were randomized to a vignette that varied by race-ethnicity, crime type, and grief trajectory to assess their perceptions. Results indicated: (1) participants perceived prolonged grief as less appropriate than resilience; (2) Black family members grieving someone who committed a violent crime as more appropriate compared to White family members; and (3) women endorsed both grief trajectories as more appropriate and indicated greater comfort supporting the family member. Lastly, participants indicated prolonged, White and Latinx grievers should seek therapy more than resilient or Black individuals.

The Function of Connection: Examining Social Supports in the Lives of Parentally Bereaved Youth

Through reflexive thematic analysis, this study explored three forms of social support in the lives of parentally bereaved youth: support derived from one's spirituality, caregiver support via parent-child communication, and therapist support from grief counseling (N = 30 youth, Mage = 12.5 years, SD = 2.8 years). Results showed that these sources of support serve varied and vital functions in the lives of parentally bereaved youth. Namely, the benefits of grief counseling and spirituality were consistently identified by youth as critical in facilitating their coping with the loss of a parent; while parent-child communication regarding the deceased varied widely, highlighting the need for additional supports beyond their surviving caregiver. Findings also revealed differences among these supports across youth gender, race, ethnicity, and age. Adolescents were more likely to disengage from counseling services and reported less parental and spiritual support. Males and minoritized youth experienced more benefits from spiritual and therapist supports.

Bereavement care provision and its associated factors among nurses in cancer care settings: a cross-sectional study

PURPOSE

The goals of this study were to (1) investigate bereavement care provision in practical settings, (2) examine the difference in care by nurses' affiliation (general hospital, hospice, or homecare setting), and (3) identify institutional and personal barriers associated with bereavement care provision.

METHODS

A cross-sectional survey was conducted using an online questionnaire. Nurses (n = 309) who had an experience of cancer patient care before death at least once in a previous year were included in the analysis. Kruskal-Wallis test and Mann-Whitney test were conducted to compare bereavement care provision by nurses' affiliation, and hierarchical logistic regression analysis was conducted to investigate the correlation between bereavement care provision and its associated factors.

RESULTS

Less than 30% of nurses reported providing bereavement care in structured settings such as home visits, counseling at a hospital, or phone calls. The differences in bereavement care provision by nurses' affiliation were significant, and the nurses working in a hospital were less likely to provide bereavement care than those working in a hospice or homecare setting. Working in a palliative care setting (OR = 2.35, 95%CI 1.09-5.07, p < 0.05) and greater confidence (OR = 2.18, 95%CI 1.07-4.42, p < 0.05) and knowledge regarding bereavement care (OR = 12.46, 95%CI 5.69-27.29, p < 0.001) were significantly associated factors of bereavement care provision.

CONCLUSION

This study indicated a lack of bereavement care provision, especially in general hospitals. Improving nurses' confidence and knowledge may encourage them to provide bereavement care provision.

Co-Occurring Substance Use Disorders and Grief during Recovery

BACKGROUND

Individuals with substance use disorders (SUDs) often experience loss and grief when recovering from addiction. With fatal overdoses and suicide rates increasing for individuals with SUDs and other mental health concerns, individuals in recovery are often faced with mourning the loss of a loved one while navigating their life in recovery. The loss of a loved one can be compounded by the effect of losing their relationship with their drug of choice. These co-occurring losses may prove overwhelming during recovery and precipitate a relapse.

OBJECTIVES

We wish to propose the use of two bereavement models to address the grief present for individuals with SUDs experiencing loss so that providers are better able meet the complex needs of this population.

METHODS

This article presents two separate bereavement models that may be used to shape treatment for individuals in recovery from addiction with co-occurring grief from the loss of a loved one: the dual-process model of coping with bereavement (DPM) and the two-track model of bereavement.

RESULTS

We propose the application of these two grief models in treatment for individuals with SUDs who are experiencing co-occurring grief issues. We discuss therapeutic interventions that may be utilized to support clients with co-occurring losses.Conclusion/Importance: If an individual experiences the loss of a loved one while navigating their life in recovery from a SUD, they can experience complicated grief due to co-occurring losses. These models provide an opportunity for mental health providers to help those with SUDs work through this complex grief.

Effectiveness and Feasibility of Internet-Based Interventions for Grief After Bereavement: Systematic Review and Meta-analysis

BACKGROUND

Although grief and its symptoms constitute a normal reaction to experiences of loss, some of those affected still report elevated levels of distress after an extended period, often termed complicated grief. Beneficial treatment effects of face-to-face therapies, for example, grief counseling or cognitive behavioral therapy against complicated grief, have been reported. Evaluations of internet- and mobile-based interventions targeting symptoms of grief in bereaved individuals with regard to objective quality criteria are currently lacking.

OBJECTIVE

We aim to conduct a systematic review and meta-analysis on the effectiveness and feasibility of internet- and mobile-based interventions against symptoms of grief after bereavement.

METHODS

We conducted systematic literature searches of randomized controlled trials or feasibility studies published before January 9, 2020, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, in PubMed, PsycINFO, Web of Science Core Collection, and the Cochrane Library. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations system. We further assessed aspects of feasibility and rated quality of interventions using criteria suggested by an expert panel on mental health care (German Association for Psychiatry, Psychotherapy, and Psychosomatics). A random-effects meta-analysis was conducted to assess between-group effect sizes.

RESULTS

In total, 9 trials (N=1349) were included. Of these, 7 studies were analyzed meta-analytically. Significant effects were found for symptoms of grief (g=0.54, 95% CI 0.32-0.77), depression (g=0.44, 95% CI 0.20-0.68), and posttraumatic stress (g=0.82, 95% CI 0.63-1.01). Heterogeneity was moderate for grief and depression (I2=48.75% and 55.19%, respectively) and low for posttraumatic stress symptoms (I2=0%). The overall quality of evidence was graded low (grief and depression) to moderate (posttraumatic stress). User satisfaction with the interventions was high, as was the quality of the interventions assessed using objective quality criteria.

CONCLUSIONS

Internet- or mobile-based interventions might constitute an effective treatment approach against symptoms of grief in bereaved adults. However, the small sample sizes and limited number of studies included in the review warrant further investigation.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42012002100; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131428.

A study to determine if and how bereavement support programs provided by Irish and Canadian hospices are evaluated

A study of the bereavement programs provided by hospices in Ireland and the Canadian province of Alberta was done to determine if and how these are evaluated for efficacy. All but one hospice offered multiple different bereavement programs, with routine in-house evaluations of all programs performed. In all cases, staff and client unsolicited and solicited comments made during and at the end of each program provided data for continuing program refinement. Most hospices also routinely employed a self-devised questionnaire to gain specific sought information to retain or change programs. Other information, including news about program developments elsewhere, was also actively sought for program adoption or for the improvement of existing programs. With most bereavement programs having been in place for many years, participants were confident their programs are needed, safe, and effective. Their continuing quest for high-quality programming, however, meant they were active in monitoring these programs and in seeking developments in this field.

The Integration of Stressful Life Experiences Scale and the Inventory of Complicated Spiritual Grief: The Italian Validation of Two Instruments for Meaning-Focused Assessments of Bereavement

Background: Bereavement is an inevitable event that can cause pain, discomfort, and negative consequences in daily life. Spirituality and religiosity can help people cope with loss and bereavement. Sometimes, however, the death of a loved one can challenge core religious beliefs and faith, which has been found to be a risk factor for prolonged mourning. Objectives: (1) Determine whether the Italian versions of the Integration of Stressful Life Experiences Scale (ISLES) and Inventory of Complicated Spiritual Grief (ICSG) are valid in translation; (2) Evaluate the impact of socio-demographic variables on ISLES and ICSG dimensions; (3) Test whether Complicated Spiritual Grief mediates the relation between meaning reconstruction after loss and integration of the loss experience; (4) Test whether the representation of death as a form of passage or annihilation further moderated the relation between Complicated Spiritual Grief and integration of the loss. Methods: The sample is composed of 348 participants who had lost a loved person in the prior two years. Results: The ISLES and ICSG were validated in Italian and are more appropriately interpreted as having a unifactorial structure. A greater spiritual crisis was manifested in participants with less education, who did not actively participate in religious life, and who had lost a friend rather than a close relative. As hypothesised, spiritual struggle in grief mediated the role of continuing bonds, Emptiness and Meaninglessness, and Sense of Peace in predicting integration of the loss. Furthermore, death representation moderated the impact of spiritual grief on loss, such that those participants who viewed death as a form of annihilation rather than passage reported greater integration of the loss. Conclusion: The role of meaning making in integrating significant loss is partly accounted for by spiritual struggle in a way that can be analysed in Italian contexts through the use of these newly validated instruments.

Psychological Interventions for Individuals Bereaved by Homicide: A Systematic Review

Research has demonstrated that approximately 45-50% of individuals show healthy levels of psychological and physical functioning in the first 12 months post-loss. Homicidal bereavement (loss due to murder or manslaughter) does not appear to follow this pattern. Homicide-related mental health difficulties are a serious problem worldwide, displaying high rates of lifetime incidence, high chronicity, and role impairment. Individuals are at increased risk to develop symptoms of post-traumatic stress disorder (PTSD), complicated grief (CG), and depression. Nevertheless, a systematic review specifically on the efficacy of psychological interventions following homicidal loss has not yet been conducted. The current systematic review (registered via PROSPERO) aimed to review the psychological interventions available and report their effectiveness. Of 77 records, 7 met predefined inclusion criteria. Studies presented different methodologies, tested different clinical models, and treatment conditions. Thus, a narrative systematic review was conducted. Studies included manualized interventions to deliver 1:1 and group sessions. Cognitive behavioral therapy, restorative retelling, and eye movement desensitization and reprocessing were the main models used together with psychoeducational elements about trauma and grief responses. Overall, symptoms of PTSD, CG, and depression decreased significantly postintervention. Sustained improvements were reported for PTSD and depressive symptoms at the follow-up measurements. Mixed results were found regarding how individual (age, gender) and external factors (time since loss, relationship with the deceased) impact on symptom progression. As a result of differences in methodologies, categorization of therapies, methodological differences, and small sample sizes, important questions remain unanswered. Further randomized controlled trials and expert consensus could be considered.

Grief and bereavement beliefs among U. S. mental health professionals and the general public

The present study examined beliefs about grief and bereavement in a sample of mental health professionals and the general public in the United States. In part 1 of this study, we developed a 12-item questionnaire based on extant thanatology literature and expert review. In part 2, 210 participants rated their beliefs about grief and bereavement using this questionnaire. Participants rated most items accurately, and mental health professionals were more likely to answer items accurately compared to the general public. These findings provide support for increasing grief literacy in professional and public domains.

Adding a New Dimension to Grief Counseling: Creative Personal Ritual as a Therapeutic Tool for Loss, Trauma and Transition

This article explores the use of creative personal rituals and ceremonies for accepting loss, managing strong emotions and inviting the sacred into the grief journey. These tools can help clinicians incorporate spirituality and multi-cultural modalities into a grief counseling practice, and can be used effectively by both intuitive and instrumental grievers. The use of ritual and ceremony can also help end-of-life and bereavement professionals become more present for the dying, and more competent in spiritual meaning-making for the bereaved.

The Impact of Police Behavior During Death Notifications on Mental Health of the Bereaved: A Cross-Sectional Study

The delivery of death notifications may affect the mental health of bereaved individuals. Police officers are often the first people with whom the bereaved have contact in this exceptional situation. Therefore, it is essential to assess the behavior of police officers and the impact on the bereaved. We examined the experiences of 86 individuals who received the notification through the police and assessed symptoms of prolonged grief, depression, and posttraumatic stress symptoms. The interaction with police was associated with posttraumatic avoidance behavior and the presence of another supporting person was associated with higher scores of depression. Handing out information material and staying with the bereaved was related to a positive evaluation of police behavior. It appears important to identify helpful and problematic behavior for a better understanding and for an adaptation of existing guidelines.

Quality of Life for Older Cancer Patients: Relation of Psychospiritual Distress to Meaning-Making During Dignity Therapy

BACKGROUND

Nearly 500,000 older Americans die a cancer-related death annually. Best practices for seriously ill patients include palliative care that aids in promoting personal dignity. Dignity Therapy is an internationally recognized therapeutic intervention designed to enhance dignity for the seriously ill. Theoretically, Dignity Therapy provides opportunity for patients to make meaning by contextualizing their illness within their larger life story. The extent to which Dignity Therapy actually elicits meaning-making from patients, however, has not been tested.

AIM

The current study examines (i) extent of patient meaning-making during Dignity Therapy, and (ii) whether baseline psychospiritual distress relates to subsequent meaning-making during Dignity Therapy.

DESIGN

Participants completed baseline self-report measures of psychospiritual distress (i.e., dignity-related distress, spiritual distress, quality of life), before participating in Dignity Therapy. Narrative analysis identified the extent of meaning-making during Dignity Therapy sessions.

PARTICIPANTS

Twenty-five outpatients (M age = 63, SD = 5.72) with late-stage cancer and moderate cancer-related symptoms were recruited.

RESULTS

Narrative analysis revealed all patients made meaning during Dignity Therapy but there was wide variation (i.e., 1-12 occurrences). Patients who made greater meaning were those who, at baseline, reported significantly higher psychospiritual distress, including greater dignity-related distress (r = .46), greater spiritual distress (r = .44), and lower quality of life (r = -.56).

CONCLUSION

Meaning-making was found to be a central component of Dignity Therapy. Particularly, patients experiencing greater distress in facing their illness use the Dignity Therapy session to express how they have made meaning in their lives.

The impacts and effectiveness of support for people bereaved through advanced illness: A systematic review and thematic synthesis

BACKGROUND

Bereavement support is a key component of palliative care, with different types of support recommended according to need. Previous reviews have typically focused on specialised interventions and have not considered more generic forms of support, drawing on different research methodologies.

AIM

To review the quantitative and qualitative evidence on the effectiveness and impact of interventions and services providing support for adults bereaved through advanced illness.

DESIGN

A mixed-methods systematic review was conducted, with narrative synthesis of quantitative results and thematic synthesis of qualitative results. The review protocol is published in PROSPERO ( www.crd.york.ac.uk/prospero , CRD42016043530).

DATA SOURCES

The databases MEDLINE, Embase, PsycINFO, CINAHL and Social Policy and Practice were searched from 1990 to March 2019. Studies were included which reported evaluation results of bereavement interventions, following screening by two independent researchers. Study quality was assessed using GATE checklists.

RESULTS

A total of 31 studies were included, reporting on bereavement support groups, psychological and counselling interventions and a mix of other forms of support. Improvements in study outcomes were commonly reported, but the quality of the quantitative evidence was generally poor or mixed. Three main impacts were identified in the qualitative evidence, which also varied in quality: 'loss and grief resolution', 'sense of mastery and moving ahead' and 'social support'.

CONCLUSION

Conclusions on effectiveness are limited by small sample sizes and heterogeneity in study populations, models of care and outcomes. The qualitative evidence suggests several cross-cutting benefits and helps explain the impact mechanisms and contextual factors that are integral to the support.

Management of Grief, Depression, and Suicidal Thoughts in Serious Illness

The varied physical, social, and psychological stressors that accompany advanced disease can be burdensome and cause intense emotional suffering, hindering the ability of patients and families to cope in day-to-day life and negatively affecting quality of life. This article addresses key concepts for the assessment and management of commonly encountered types of psychological distress in serious illness including grief, prolonged grief, major depressive disorder, death contemplation, and suicidal ideation.

The value of implementation science in bridging the evidence gap in bereavement care

There is a gap in the use of evidence in bereavement care. Implementation science is a field focused on moving evidence into practice and therefore may help close the gap. Implementation science advances the design, relevance, and dissemination of research and the adoption, implementation, and maintenance of evidence-based practices. We provide an overview of implementation science, describe five implementation frameworks (Knowledge to Action; Behavior Change Wheel; Exploration Preparation Implementation Sustainment; Interactive Systems Framework; and Reach, Adoption, Implementation, Maintenance), and illustrate their application in bereavement care. These advancements will promote high-quality bereavement care that improves the lives of bereaved people.

Coping and wellbeing in bereavement: two core outcomes for evaluating bereavement support in palliative care

BACKGROUND

Bereavement support is a core part of palliative care. However, the evidence base is limited by a lack of consistency in the outcomes used to evaluate services and models of support, which makes it difficult to compare approaches. Core Outcome Sets (COS) represent the minimum that should be measured in research into specific conditions or services. The aim of this study was to use a stakeholders' perspective to develop a COS for evaluating bereavement support for adults in adult palliative care settings.

METHODS

A list of outcomes relevant to bereavement support was created following a systematic review of the quantitative and qualitative literature. At an expert workshop 21 stakeholders discussed their views on the most important outcomes and compared these to and critiqued the lists constructed from the review. These lists and discussions informed a two round international DELPHI survey (n = 240) designed to reach consensus on which outcomes/outcome dimensions should be included in the COS. To prioritise and validate the items emerging from the survey, participants at a subsequent consensus day ranked the relative importance of these items (n = 23). A final feedback exercise with these consensus day participants was conducted to confirm the selection of outcomes and dimensions.

RESULTS

'Ability to cope with grief' and 'Quality of life and mental wellbeing' were selected as two core outcomes. Twenty-one different dimensions to explore when assessing these outcomes were also identified. The coping related dimensions have been categorised as: Negative and overwhelming grief; Communication and connectedness; Understanding, accepting and finding meaning in grief; Finding balance between grief and life going forwards; Accessing appropriate support. Those relating to quality of life and wellbeing have been categorised as; Participation in work and/or regular activities; Relationships and social functioning; Positive mental wellbeing and Negative mental and emotional state.

CONCLUSION

This COS outlines a more consistent way forward for bereavement researchers and practitioners, whilst also orientating towards public health and resilience-based approaches to bereavement care. Further work is planned to identify and develop measures which are specific to this core outcome set, and which will facilitate the future comparability of bereavement services and interventions.

Response to spousal death according to faith in traditional Chinese culture among older Chinese: Moderation by occupation

This study aims to enrich the knowledge of the effects of traditional Chinese culture on bereavement outcomes among older Chinese, and to examine the moderating role of occupation in the relationship between traditional culture and bereavement outcomes. A sample of 352 older Chinese in widowhood was interviewed by quota sampling. A scale of faith in traditional Chinese culture was developed and confirmed by factor analysis. Complicated grief (CG) functioned as the outcome variable. Results showed that faith in traditional culture did affect CG among the sample, and previous occupation moderated the effect of traditional culture on CG. That is, the effect of faith in Chinese culture on CG is stronger in the non-peasant group than the peasant group. The results broaden the knowledge of spousal bereavement in a Chinese context. Services such as death education and occupational therapy were recommended according to this study.

Developing a practice-based research agenda for grief and bereavement care

We aimed to identify practitioners' perspectives on current research priorities in grief and bereavement care. Grief and bereavement care providers were invited to participate in a three-phase Delphi study to create expert consensus on the top priorities for grief and bereavement research. A total of 140 participants completed Phase 1, 84 completed Phase 2, and 70 completed Phase 3. These top 10 research priorities form the basis of a practice-based research agenda for grief and bereavement care to enable researchers to respond to key issues in grief and bereavement care that will ultimately improve the lives of bereaved people.

Improving bereavement outcomes in Zimbabwe: protocol for a feasibility cluster trial of the 9-cell bereavement tool

Background

The high burden of bereavement in sub-Saharan Africa is largely attributable to HIV, cancer, and other non-communicable diseases. However, interventions to improve grief and bereavement are rare. Given high rates of mortality in the context of weak health systems, community lay members are well placed to provide peer bereavement support. The 9-cell bereavement tool was developed in Zimbabwe to improve community members’ capacity to support the bereaved. This study aims to determine the feasibility of implementing the 9-cell bereavement tool and recruitment to experimental evaluation.

Methods/design

This feasibility cluster randomized trial with embedded qualitative interviews will be conducted in two comparable neighborhoods in Zimbabwe. Community leaders from each neighborhood will identify 25 potential community lay bereavement supporters, each of whom will recruit 2–3 bereaved community members into the trial. The intervention will be randomly allocated to one community, and the second community will form a wait-list control (n ≥ 75 in each community cluster). Recruitment is estimated to take place over 3 weeks. Measures at T0 (baseline, i.e., week 0), T1 (midline, i.e., week 14 or 3 months post-baseline) and T2 (endline, i.e., week 27 or 3 months post-midline) will address mental health, social support, and levels of grief per individual. Qualitative data will describe lay supporters’ views of intervention training and delivery, and participants’ experience of bereavement support.

Discussion

This is the first documented trial evaluating a bereavement intervention in sub-Saharan Africa. Recruitment, retention, and measurement data will determine the feasibility of a full trial.

Trial registration

ISRCTN, ISRCTN16484746. Registered 6 February 2018

Issues in Pediatric Palliative Care: Understanding Families

While family-centred care has always been Part of the rhetoric of hospice and palliative care, few models have been developed that successfully integrate care of the caregivers into the overall schema. Systematic analyses of interventions have failed to produce any demonstrable benefit to families arising from the modern practice of palliative care. This alarming finding constitutes the greatest challenge for the 21st century. Pediatric palliative care may have much to teach in its approach to family care. Family-focused grief therapy is one model, used with both adolescent and adult families, that has promise for the field. The time has surely arrived for palliative medicine to focus on family-based research.

Suicide Postvention for the United States Military: Literature Review, Conceptual Model, and Recommendations

Suicide continues to be a significant public health problem in the United States and the Department of Defense (DoD). Timely and systematic postvention efforts can play an instrumental role in helping family members, peers, and military command to best manage the aftermath of a suicide. To date, several postvention efforts have been implemented in the military. However, there continues to be an overall lack of understanding of the specific short- and long-term effects of exposure to military suicide. In addition, more emphasis needs to be placed on empirically driven approaches to postvention and program evaluation. The purpose of this article is threefold: (1) to provide a summary of the postvention literature with special emphasis placed on the military organization; (2) to propose a conceptual model as a framework for understanding Military-Unit Suicide Survivorship; and (3) to briefly highlight postvention strategies within the DoD in the context of a number of research, clinical, and policy recommendations.

Early intervention for bereaved children: What mental health professionals think

People rarely specify what "early intervention" following bereavement means, so we explored the views of experienced professionals working primarily with bereaved children. In an anonymous online survey, 84 mental health professionals answered questions about the content and timeframe of early intervention. The types of interventions varied, but conversation and support were most frequent. Most considered early intervention to mean before or during the first month following the loss. Although meta-analyses show little benefit of early intervention, professionals disagree and see the need to tailor interventions to the type of death, the situation of the family, and the intensity of reactions.

Reflections on the development of a therapeutic recreation-based bereavement camp for families whose child has died from serious illness

While bereavement camps serve as a support for children, this study examines a therapeutic recreation-based camp for families who have lost a child. The study triangulated documents, researcher reflection, and staff interviews to highlight the themes of Searching & Finding, Getting to Know, Finding the Balance, and Joining. Developing opportunistically through internal and external factors, the camp's evolution represents a closing of the loop, from supporting families of living children to also supporting the families of children who have died. Understanding the camp's evolution may facilitate other programs by highlighting the challenges in developing the program and the lessons learned.

Communication Disparity Between the Bereaved and Others: What Hurts Them and What Is Unhelpful? A Nationwide Study of the Cancer Bereaved

CONTEXT

The importance of communication between the cancer bereaved and others has been emphasized, but little is known about the more problematic aspects of this communication such as "unhelpful communication."

OBJECTIVES

The aim of this study was to establish which types of communication are perceived by the bereaved to be unhelpful.

METHODS

We conducted a cross-sectional, anonymous, nationwide survey at 103 certified hospice facilities/palliative care units in Japan.

RESULTS

A total of 630 (63%) bereaved responded. Over 60% of the bereaved experiencing such communication considered it to be unhelpful, with the most unhelpful communication being "They emphasized the positive aspects of death." Thirteen items related to communication were separated into two factors ("advice for recovery" and "comments on cancer") by factor analysis. "Comments on cancer" were more unhelpful to them and were more often provided by those around them. With regard to "advice for recovery," losing a spouse was a stronger predictor with a higher odds ratio for communication distress than losing a parent (odds ratio, 5.34; 95% CI, 1.63-17.57).

CONCLUSION

A number of the bereaved have experienced unhelpful communication regarding advice on dealing with bereavement and cancer. To prevent putting an unnecessary burden on the bereaved with such unhelpful communication, it is essential to understand problematic aspects. Even when people have no intention of hurting the bereaved, some communication may do so. Communication with the bereaved is also a core clinical skill required by health professionals, and further efforts are required to support the grieving process.

End-of-Life and Bereavement Care in Pediatric Intensive Care Units

Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.

Same-sex partner bereavement in older women: an interpretative phenomenological analysis

OBJECTIVES

Due to the lack of existing literature, the current research explored experiences of same-sex partner bereavement in women over the age of 60.

METHOD

Semi-structured interviews were conducted with eight women. Transcripts were analysed using interpretative phenomenological analysis.

RESULTS

Three themes were identified which elaborated the experiences of older women who had lost a same-sex partner: (1) being left alone encapsulated feelings of isolation and exclusion; (2) navigating visibility centred on how homophobia led to a lack of recognition of the women's grief; and (3) finding new places to be authentic related women's need for new relationships in which they could be themselves. The findings indicate that existing models of partner bereavement may provide useful frameworks when seeking to understand the experiences of older women who have lost their same-sex partners.

CONCLUSION

The findings indicate that in addition to the experiences of partner bereavement noted in research with heterosexual widows, older women who lose same-sex partners may face particular challenges, which can impact upon psychological well-being and adjustment to loss. These challenges appear to result from past and current homophobic and heterosexist attitudes within the UK culture. A range of interventions at individual, group, health service, and societal levels may be beneficial in improving the psychological well-being of older women who lose a same-sex partner.

Complicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review

OBJECTIVE

A systematic review and qualitative synthesis was undertaken to deduce the knowledge, attitudes, skills and training of mental health professionals regarding complicated grief (CG).

METHODS

PsychInfo, Embase, Medline, CINAHL, PBSC, Web of Science and ERIC databases were used to identify relevant literature. Searches were executed from inception to September 2014.

RESULTS

The electronic search yielded 305 results. Forty-one papers were selected for full text review, 20 were included for analysis. 6 examined primary data, the remaining 14 being reviews, opinion or guideline pieces.

CONCLUSIONS

Despite the lack of consensus on terminology, criteria and diagnosis, it appears that there is more than sufficient agreement within the CG research community regarding the knowledge and skills required to assist someone presenting with CG. A palpable fear of medicalising grief exists, but this would seem to be based on a conflation of normal grief and CG. This review highlights the mainly unidirectional nature of current research, the voice of the practitioner being largely unheard. A need for and an interest in training in CG was expressed.

PRACTICE IMPLICATIONS

There is an urgent need to translate research findings into clinical practice. Training must take account of attitudinal barriers to implementation, balancing evidence and stories.

Early Interventions Following the Death of a Parent: Protocol of a Mixed Methods Systematic Review

BACKGROUND

Previous meta-analyses examined the effectiveness of interventions for bereaved children showing small to moderate effect sizes. However, no mixed methods systematic review was conducted on bereavement interventions following the loss of a parent focusing on the time since death in regard to the prevention of grief complications.

OBJECTIVE

The overall purpose of the review is to provide a rigorous synthesis of early intervention after parental death in childhood. Specifically, the aims are twofold: (1) to determine the rationales, contents, timeframes, and outcomes of early bereavement care interventions for children and/or their parents and (2) to assess the quality of current early intervention studies.

METHODS

Quantitative, qualitative, and mixed methods intervention studies that start intervention with parentally bereaved children (and/or their parents) up to 6 months postloss will be included in the review. The search strategy was based on the Population, Interventions, Comparator, Outcomes, and Study Designs (PICOS) approach, and it was devised together with a university librarian. The literature searches will be carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, Excerpta Medica Database (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The Mixed Methods Appraisal Tool will be used to appraise the quality of eligible studies. All data will be narratively synthetized following the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.

RESULTS

The systematic review is ongoing and the data search has started. The review is expected to be completed by the end of 2017. Findings will be submitted to leading journals for publication.

CONCLUSIONS

In accordance with the current diagnostic criteria for prolonged grief as well as the users' perspectives literature, this systematic review outlines a possible sensitive period for early intervention following the death of a parent. The hereby presented protocol ensures the groundwork and transparency for the process of conducting the systematic review.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42017064077; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017064077 (Archived by WebCite at http://www.webcitation.org/6rMq6F0fv).

The meaning and experience of bereavement support: A qualitative interview study of bereaved family caregivers

Objective:

Experiences of bereavement can be stressful and are frequently complicated by emotional, familial, and financial issues. Some—though not all—caregivers may benefit from bereavement support. While considered standard within palliative care services in Australia, bereavement support is not widely utilized by family caregivers. There is little research focused on the forms of bereavement support desired or required by family caregivers, how such care is viewed, and/or how bereavement support is experienced. This study examined the experiences of bereaved family caregivers and their impressions of and interactions with bereavement support.

Method:

This paper reports on one aspect of a broader study designed to explore a range of experiences of patients and caregivers to and through palliative care. Focusing on experiences of bereavement, it draws on qualitative semistructured interviews with 15 family caregivers of palliative care patients within a specialist palliative care unit of an Australian metropolitan hospital. The interviews for this stage of the study were initiated 3–9 months after an initial interview with a family caregiver, during which time the palliative patient had died, and they covered family caregivers' experiences of bereavement and bereavement support. Interviews were digitally audiotaped and transcribed in full. A thematic analysis was conducted utilizing the framework approach wherein interview transcripts were reviewed, key themes identified, and explanations developed.

Results:

The research identified four prevalent themes: (1) sociocultural constructions of bereavement support as for the incapable or socially isolated; (2) perceptions of bereavement support services as narrow in scope; (3) the “personal” character of bereavement and subsequent incompatibility with formalized support, and (4) issues around the timing and style of approaches to being offered support.

Significance of results:

Systematic pre-bereavement planning and careful communication about the services offered by palliative care bereavement support centers may improve receipt of support among bereaved family caregivers in need.

Potential Use of Ayahuasca in Grief Therapy

The death of a loved one is ultimately a universal experience. However, conventional interventions employed for people suffering with uncomplicated grief have gathered little empirical support. The present study aimed to explore the potential effects of ayahuasca on grief. We compared 30 people who had taken ayahuasca with 30 people who had attended peer-support groups, measuring level of grief and experiential avoidance. We also examined themes in participant responses to an open-ended question regarding their experiences with ayahuasca. The ayahuasca group presented a lower level of grief in the Present Feelings Scale of Texas Revised Inventory of Grief, showing benefits in some psychological and interpersonal dimensions. Qualitative responses described experiences of emotional release, biographical memories, and experiences of contact with the deceased. Additionally, some benefits were identified regarding the ayahuasca experiences. These results provide preliminary data about the potential of ayahuasca as a therapeutic tool in treatments for grief.

Dialectical Behavior Therapy Skills Training for Persistent Complex Bereavement Disorder

Although the majority recovers from the death of a loved one, nearly 5% exhibit persistent symptoms of grief, known as Persistent Complex Bereavement Disorder (PCBD). PCBD has adverse health, social, and psychological consequences. We examined the effectiveness of dialectical behavior therapy (DBT) skills training with a 57-year-old African American woman who met the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for PCBD and Persistent Depressive Disorder. The client met with a graduate student therapist (i.e., the second author) who applied DBT skills training on an individual basis. By the end of treatment, the participant no longer met the criteria for either of these disorders. Reliable and clinically significant reduction in her grief and depressive symptoms, suicidality, and sleep difficulties were noted from pre- to posttreatment and maintained for 2 months post treatment. Furthermore, she improved her ability to regulate her emotions and cognitions using DBT coping skills and eliminated substance abuse. These results prompt the need for more research to further investigate DBT skills training for PCBD.

Complicated Grief and the Quest for Meaning: A Constructivist Contribution

One of the more important results of the upwelling of research on bereavement in recent decades has been the development of criteria for complicated grief, a disorder whose coherence, correlates and consequences have been subjected to increasing scrutiny. In this article I argue that clinical, conceptual, and evidence-based considerations converge to support the further refinement of such criteria, with a special emphasis on their connection to the protracted and painful quest for meaning that characterizes a subset of the bereaved. As further research supports and extends these current efforts, there is reason to believe that an understanding of complicated grief can make a significant contribution to research, theory, and practice concerning adaptation in the wake of loss.