When does grief require clinical intervention?

Dear Dr. Neimeyer,

I am a nurse who works in a palliative care unit of a major metropolitan hospital, where I specialize in bereavement care.  Although the work is very satisfying, it is also frustrating, as I seem to be flooded with referrals for grief therapy from several hospital units when a patient dies, and the family responds with what I would regard as appropriate displays of emotion.  Although many are understandably immersed in grief, few really seem to need treatment, and their referral simply increases my administrative demands to a point that it is hard to meet the needs of those who really do need care.

So I have two questions.  One is, how can we distinguish between normal grief and the sort that requires clinical intervention?  And the second is, how can I get staff to stop referring inappropriate cases to me so that I can do a better job with those in genuine need?

Maria Teresa

Dear Maria Teresa,

I hear your frustration, which seems to be born of both the compassionate intention to provide care to mourning families genuinely struggling with their loss and the humble recognition that most people do not require grief therapists to respond adaptively to the sad transition the loss of a family member represents.  Distinguishing these sometimes ambiguous groups would be one useful step toward clarifying who needs professional help, versus peer or family support in their grieving.  Let me offer four ideas that might be helpful in addressing your concerns.

First, it is important to recognize that some forms of loss are indeed likely to have poor outcomes without specialized support.  For example, research suggests that such objective factors as sudden and violent death (e.g., suicide, homicide, fatal accident) and the death of a child or young person are more likely to lead to complications in grieving and higher degrees of traumatic and depressive symptomatology.  But so too are more subjective factors, such as psychological dependency on a dying partner, lack of social support, a general sense of insecurity in close attachments, caregiver burden, a struggle to make sense of the loss and poor management of the death notification process in the hospital.  These latter risk factors might call for more careful assessment than referring staff are likely able to make.  However, even when one or more of these risk factors is present, it is worth noting that most people manage well without professional care, finding their footing again after some months.  In other words, resilience in the face of loss, is, just as you have observed, the norm—even though those with the sorts of risks noted above are more likely than others to experience a prolonged struggle.

Second, a good deal of evidence now exists to help professionals distinguish between normal, adaptive grieving on the one hand and complicated or protracted grief courses on the other.  In fact, based on hundreds of studies, Prolonged Grief Disorder, with its focus on anguished preoccupation with the loss or yearning for the deceased, high levels of anxiety, depression or guilt regarding the death, and significant disruption of one’s work, family and social life, for the first time will be recognized in the World Health Organization’s International Classification of Diseases (ICD-11) in 2018.  However, it it important to note that the 10% of the bereaved who are likely to qualify for this diagnosis must have struggled with such symptoms for a year or more, meaning that a diagnosis of prolonged grief by definition cannot be made in the near aftermath of the death.  What would be required would be longer term follow-up, perhaps in terms of screening calls at 6 and 12 months after the loss, to identify those survivors requiring preventive interventions or ongoing therapy.  Few institutions, however, currently meet this standard of care, at least outside hospice settings.

Third, and as a related point, consider what can nonetheless be accomplished in a single screening consultation.  For example, research has established that women who lose a husband may be 10 times more likely to die by suicide in the early weeks of bereavement than married women, and that men who lose their wives may be at over 60 times the risk of killing themselves in the same period.  This might not be diagnosable as complicated grief, but many other conditions ranging from suicide risk through depression to various forms of family conflict can all be observed in the near aftermath of loss, warranting professional screening when warning signs are observed.  However, this is likely to apply to a very small percentage of the bereaved overall, the great majority of whom might benefit from practical and emotional support of a nonprofessional type, and especially when meaningful relationships have developed with staff over the course of months, appropriate professional expression of compassion, as through participation in memorial services or acknowledgment of the loss through correspondence and other forms of contact.

Finally, your question suggests the relevance of offering continuing education on the diagnosis of prolonged grief and other complications for medical, nursing, chaplaincy and psychosocial staff at your hospital.  The goal of this training or grand rounds would be to share some of the recent developments in bereavement research, help your colleagues understand what does and does not require referral, encourage the development of appropriate supportive protocols for normal, adaptive grievers, and to “put a face” on the distinctions between these and more complicated cases through offering prototypical case studies.  With a clearer sense of who needs professional grief therapy, who needs screening, and who simply needs routine non-professional support, your colleagues are likely to make fewer and more informed referrals, leaving you more time to serve those who require your care.

Dr. Neimeyer