Dear Dr. Neimeyer,
I am a social worker with a large hospice bereavement center that offers community support services for grieving people of all kinds, not only surviving family members after a loved one dies in our home care or residential facility. But recently we’ve been stretched thin in our outreach and response services, and are trying to make evidence-informed decisions about who to provide simply educational information (such as through brochures or our web site), who might benefit from an invitation to one of our ongoing support groups, and who might need assessment for grief therapy of a more professional or individualized kind, which might require referral to a specialist beyond the services we ourselves can offer. So our question as a team is whether there are any evidence-based risk factors for who among the bereaved are likely to experience complicated or prolonged grief, and call for a closer assessment of their needs. We’ve found some existing scales or criteria, but mostly these just seem to categorize people based on nurse’s impressions rather than actual data on who suffers the greatest risk of complication. Can you point us in a helpful direction?
One of the hazards of compassionate care is that it can be extended so widely that the safety net it provides grows thin and insubstantial, so that those whose grief is heaviest may not receive the support they need, while mourners who are likely to adapt well on their own receive attention they may not even want. But evidence is beginning to build that some grievers are at greater risk of intense and prolonged grief than others, although more research needs to be done to clarify exactly what factors in what combination are most worrisome–a task that several collaborating colleagues in our research network are undertaking even as we write. So while a strong evidence-based checklist of risk factors is still on the horizon, it is possible to scan for the following factors that dozens of recent studies individually suggest pose the prospect of poor outcomes following loss.
For the sake of clarity, let me divide these factors into those that focus on (1) the circumstances of the death, (2) the background of the bereaved, (3) their relationship to the deceased, (4) their styles of coping with the loss, and (5) the broader social and institutional systems in which they are engaged.
Circumstances of the death
- Cause of death: In general, violent death losses–through suicide, homicide, disaster and fatal accident–provoke more complicated grief than death through natural causes.
- Peri-event variables:Finding the body of a loved one, especially after violent death, as well as witnessing a loved one’s great suffering at the end-of-life, tend to intensify grief responses.
Background of the bereaved
- Gender: Other things being equal, women appear more susceptible to complicated grief than men, perhaps as a function of their deeper attachments.
- Demographic disadvantage:Poverty and lower levels of education increase the risk of bereavement complication, as mourners may have fewer tangible resources and perhaps less medical literacy to negotiate the illness and loss of a member of the family.
Relationship to the deceased
- Kinship: Other factors being equal, closer kinship to the deceased places people at greater risk of complication, although psychological closeness may be a better predictor of this than degree of legal or biological kinship per se.
- Marital dependency: Concentrating one’s emotional, financial and practical dependency on a partner places the surviving spouse at risk for feelings of decimation when widowhood occurs.
- Caregiver burden: Especially in the context of progressive illness, family caregivers can become exhausted and isolated, while also experiencing a thinning of their social network, all of which can worsen eventual bereavement.
- Attachment style: People who are chronically anxious about abandonment by others and fearful of rejection may be deeply threatened by the loss of a loved one to death, and feel too vulnerable to reach out to others afterward.
- Meaning making:Mourners who struggle to make sense of the death or their lives in its aftermath suffer more intense and protracted grief.
Social systemic and institutional factors
- Social support: Survivors with the least practical and emotional support from others are vulnerable to worse bereavement outcomes.
- Institutional responses: Disengagement by health care professionals can deprive families of the informational support and joint decision making that families require, thereby predisposing them to a sense of disempowerment and self-doubt following the death.
No single factor is likely to be definitive, but the presence of any of these factors, and particularly the co-occurrence of multiple factors, suggests that closer assessment and monitoring of survivors is indicated, coupled by referral to higher levels of care as problems emerge.