The cultural bereavement interview: a new clinical research approach for refugees

The large number of refugees in the world must cope with the loss of family and homeland. This paper proposes a new concept of cultural bereavement and presents a framework for its identification in the clinical interview with refugees. The cultural bereavement interview explores reactions to personal losses and to losses of both the social systems and the cultural meanings. Eleven areas are systematically explored, the first nine are indicators of bereavement and the tenth and eleventh are "antidotes" to cultural bereavement. The cultural bereavement interview can provide a clinical framework for exploring the patient's personal and cultural bereavement, clarify the "structure" of the patient's reactions to loss, complement the currently used psychiatric diagnostic categories, acknowledge the cultural system of meaning held by the patient, and provide information to be used in planning social supports or interventions.     

A review of the emotional, psychiatric and behavioural responses to bereavement in people with intellectual disabilities

Background Our knowledge and understanding of grief and its consequences have grown rapidly in recent years. There is a growing understanding that bereavement and loss represent a very significant event in the lives of people with intellectual disabilities (IDs). To date, there is no systematic review of the literature on the emotional, psychiatric and behavioural responses to bereavement in people with IDs. Method This comprehensive literature review firstly examines the current opinion regarding the phenomenology of pathological grief in the general population. Research examining the ability of people with IDs to understand the concept of death is explored. In addition, a systematic review of the literature looking at the emotional, behavioural and psychiatric responses to bereavement is carried out. Results Bereavement and loss have distinct effects on the mental health, behaviour and emotional lives of people with IDs. Following a bereavement, symptoms of depression and anxiety increase, and general behaviour is altered. Traumatic grief symptoms have not yet been specifically studied and quantified. Conclusions Particular difficulties are associated with researching the effects of bereavement on people with IDs. Further work needs to be done to more accurately describe the nature, time-scale, severity and frequency of the symptoms of traumatic grief in people with IDs , in order to improve assessment and treatment of affected individuals.     

Parental bereavement and the loss of a child with intellectual disabilities: a review of the literature

Inequalities in health care and other risk factors mean that children with intellectual disabilities are more likely to predecease their parents. Research on the effects on family members when a child with intellectual disability dies is sparse. In the present review, the authors describe 5 studies of bereavement in intellectual disability and then turn to general parental bereavement research to inform the field of intellectual disability. Questions for future research and some implications for services and professionals are discussed. In particular, professionals should be aware of dissatisfaction with care pre-loss, disenfranchised grief, and post-loss support needs of family members.     

Do suicide survivors suffer social stigma: a review of the literature

One of the delineating elements found in suicide bereavement versus normal bereavement is the stigma experienced by survivors. This review of the literature will provide insight into stigma as an underlying element in suicide bereavement and point to the role of health professionals in dealing with this complex issue. Historical review and empirical studies are analyzed to provide a framework for how suicide relates to natural bereavement. The conclusion is that suicide bereavement is different from natural loss. The challenge to health care providers is to sort through the complex issues surrounding the individual and their social network to find mechanisms that lead to resolution. Suicide has a profound effect on the family, friends, and associates of the victim that transcends the immediate loss. As those close to the victim suffer through bereavement, a variety of reactions and coping mechanisms are engaged as each individual sorts through individual reactions to the difficult loss. Bereavement refers to "all the physiological, psychological, behavioral, and social response patterns displayed by an individual following the loss (usually through death) of a significant person or thing" (Dunne, Dunne-Maxim & McIntosh, 1987). Bereavement following suicide is complicated by the complex psychological impact of the act on those close to the victim. It is further complicated by the societal perception that the act of suicide is a failure by the victim and the family to deal with some emotional issue and ultimately society affixes blame for the loss on the survivors. This individual or societal stigma introduces a unique stress on the bereavement process that in some cases requires clinical intervention.     

Children’s reactions to parental and sibling death

A signi.cant population of children will experience bereavement because of the death of a parent or a sibling. This grief is different from the bereavement seen in adults and needs to be understood in a developmental context. Cognitive and emotional understanding of death and dying in children gradually evolves with age. This report provides clinicians with information regarding the unique developmental elements in children that relate to the process of bereavement secondary to parental and sibling loss, risk factors for complicated grief, the warning signs of depression and anxiety beyond normal grief reaction, and the guidelines for intervention in children.     

Electroencephalographic sleep in spousal bereavement and bereavement-related depression of late life.

Although spousal bereavement in late life is common and frequently leads to major depression, the boundary between bereavement without a depressive syndrome and bereavement-related depression has been insufficiently studied from a physiological perspective. Because other forms of depression are associated with physiological changes, including sleep, we have attempted to clarify the relationship of bereavement and bereavement-related depression by investigating electroencephalographic (EEG) sleep in 31 elderly volunteers with recent spousal bereavement, stratified by the presence (n = 15) or the absence (n = 16) of major depression (Research Diagnostic Criteria). Entry into the study was limited to volunteers without a personal history of psychiatric disorder. As hypothesized, bereaved subjects with major depression had significantly lower sleep efficiency, more early morning awakening, shorter rapid eye movement (REM) latency, greater REM sleep percent, and lower rates of delta wave generation in the first nonREM (NREM) period, compared with bereaved subjects without depression. Furthermore, the sleep of bereaved subjects with single-episode major depression resembled that of elderly patients with recurrent unipolar major depression (n = 15) on measures noted above. Sleep in bereavement without depression was similar to that of 15 healthy control subjects (neither bereaved nor depressed). These findings suggest that the current DSM-III-R concept of uncomplicated bereavement is not confirmed, as the sleep patterns of subjects who develop a depressive syndrome in the context of bereavement, many of whom might be considered to have "uncomplicated bereavement" by DSM-III-R standards, are identical to sleep patterns found in major depressive episodes. To our knowledge, this is the first study of EEG sleep in spousal bereavement with and without major depression.     

Death and people with learning disabilities: empowering carers

This study investigates the provision of loss and bereavement education to carers of people with learning disabilities within a small community home. The literature that informs this study reviews the history of care of people with learning disabilities, theories of education and theories of loss and bereavement. The research approach is a micro ethnographic one. It considers the results of an evaluation of an educational session based on 12 individual needs assessment interviews. Results show increased personal insight as a result of the educational session with carers being able to identify areas of change to care provision as an outcome. In conclusion, this study shows the place and value of a ‘small scale approach to training’ and promotes proactive care provision around loss and bereavement to people with learning disabilities.     

Mental health of adolescents before and after the death of a parent or sibling

The death of a parent or sibling (family bereavement) is associated with mental health problems in approximately, 25 % of the affected children. However, it is still unknown whether mental health problems of family-bereaved adolescents are predicted by pre-existing mental health problems, pre-loss family functioning, or multiple bereavements. In this study, a prospective longitudinal assessment of change in mental health following bereavement was done in a large representative sample from the ‘Tracking Adolescents Individual Lives Survey’ (TRAILS). This is a four-wave prospective cohort study of Dutch adolescents (n = 2230) of whom 131 (5.9 %) had experienced family bereavement at the last wave (T4). Family-bereaved adolescents reported more internalizing problems, within 2 years after family bereavement, compared to the non-bereaved peers, while taking into account the level of internalizing problems before the bereavement. A clinically relevant finding was that 22 % new cases were found in family-bereaved, in comparison to 5.5 % new cases in non-bereaved. Low SES predicted more internalizing problems in family-bereaved but not in non-bereaved adolescents. Family functioning, reported by the adolescent, did not predict mental health problems within 2 years. Multiple family bereavements predicted fewer externalizing problems. In conclusion, internalizing problems increase in adolescents after family bereavement in comparison to non-bereaved and these can be predicted by pre-loss factors. Awareness among professionals regarding the risks for aggravation of mental health problems after family loss is needed.     

Attitudes to suicide following the suicide of a friend or relative: a qualitative study of the views of 429 young bereaved adults in the UK

Background

People bereaved by suicide are at increased risk of suicide attempt and suicide, but explanations for these associations remain theoretical. It is possible that the experience of suicide bereavement modifies personal attitudes towards suicide, but the nature of these changes remains unexplored. There is a need to understand personal attitudes to suicide following suicide bereavement, as this may inform the development of suicide prevention interventions. Our aim was to explore the attitudes of young adults bereaved by suicide towards their own likelihood of dying by suicide.

Methods

We conducted a cross-sectional study of staff and students aged 18–40 at 37 United Kingdom (UK) higher educational institutions in 2010. Ethical approval was granted by the UCL Research Ethics Committee. Qualitative responses to a question probing attitudes to own suicide were provided by 429 respondents who had experienced bereavement by the suicide of a close contact. We identified key themes in this dataset using thematic analysis.

Results

Analysis identified four main themes: suicide as a more tangible option (whether feared or not); identification with the deceased and awareness of shared vulnerabilities to suicide; personal determination to avoid suicide; and beliefs regarding safeguards against suicide. These themes reflected a broad split in participants' views regarding own likelihood of dying by suicide, influenced by the degree to which own suicide was feared and the extent to which they felt in control of determining a suicide death. Whilst the majority described an aversion to the idea of attempting suicide themselves, largely through an awareness of the impact on others, a minority described their experiences as having normalised suicide as a personal option.

Conclusions

The views of a sample of UK-based adults bereaved by suicide suggest that exposure to the suicide of a close friend or relative can influence attitudes to suicide in ways that could influence own risk of suicide attempt. The normalising attitudes to suicide observed in a minority of respondents could contribute to the observed association between suicide bereavement and suicide attempt.

     

Bereavement and its complications in medical patients: a guide for consultation-liaison psychiatrists

Bereaved individuals consult their physicians, including psychiatrists, at an increased frequency for the many symptoms of normal or pathological grief as well as related medical and psychiatric disorders. As many as 25 percent of patients seen by a consultation-liaison service may be suffering from recent unresolved grief. The consultation-liaison psychiatrist needs to be sensitive to the manifestations and course of bereavement in both its uncomplicated and pathological forms. This report provides an overview of these issues as a guide for the accurate assessment and treatment of this often unconsidered condition.     

PTSD Following Bereavement

Until quite recently, the only stressor considered consistent with the diagnosis of PTSD was a catastrophic, out of the ordinary, trauma that almost anyone could be expected to have a severe reaction to. Thus, PTSD was considered relatively rare among non-military populations. More recently, epidemiologic surveys have suggested that PTSD may be much more prevalent than heretofore recognized, and the DSM-IV has opened the door to a much larger variety of stressors (the A criterion). Yet, bereavement is not considered the type of stressor capable of producing PTSD. In this study, 350 newly bereaved widows and widowers were assessed for the prevalence of PTSD, its chronicity, comorbidity, and consequences. The diagnosis of PTSD was made on the basis of questionnaire items approximating the DSM-IV criteria for PTSD. At 2 months after the spouse's death, 10% of those whose spouses died after a chronic illness met criteria for PTSD, 9% of those whose spouses died unexpectedly met criteria, and 36% of those whose spouses died from unnatural causes (suicide or accident) had PTSD. Symptoms tended to be chronic in at least 40% of the subjects, almost always were associated with comorbid depression, and created substantial morbidity. The results suggested that PTSD may occur after bereavement, and, by extension, other stressors not recognized by official diagnostic systems. The A criterion needs further examination.     

Evaluating the use of benzodiazepines following recent bereavement

BACKGROUND: There is no evidence to support current advice not to use benzodiazepines after bereavement. AIMS: To determine the role of benzodiazepines in the management of bereavement. METHOD: We conducted a randomised, double-blind, placebo-controlled evaluation of the use of diazepam after recent bereavement. Participants were randomised to either 2 mg diazepam or identically packaged placebo up to three times daily. The primary outcome measure was the Bereavement Phenomenology Questionnaire. RESULTS: Thirty subjects were randomised. No evidence was found of an effect of benzodiazepines on the course of the first 6 months of bereavement (estimated mean difference of combined follow-up assessments=0.3 in favour of placebo; 95% Cl - 6.2 to +6.7). CONCLUSION: We found no evidence of a positive or negative effect of benzodiazepines on the course of bereavement.     

Line-of-duty death: psychological treatment of traumatic bereavement in law enforcement

A line-of-duty death (LODD) strikingly brings home the risk and vulnerability of all law enforcement officers and affects the officer's peers, the entire department, the wider police community, and the officer's family. This article will place LODD in the context of general bereavement psychology, as well as describe some of its unique features. A variety of supportive and psychotherapeutic measures will be offered for helping peer and family survivors cope with this type of tragedy. This is one important area where police psychologists and community mental health clinicians can be of tremendous service in applying their specialized training in trauma therapy and grief counseling to the special needs of law enforcement and emergency services.     

Physiological correlates of bereavement and the impact of bereavement interventions

The death of a loved one is recognized as one of life's greatest stresses, with reports of increased mortality and morbidity for the surviving spouse or parent, especially in the early months of bereavement. The aim of this paper is to review the evidence to date to identify physiological changes in the early bereaved period, and evaluate the impact of bereavement interventions on such physiological responses, where they exist. Research to date suggests that bereavement is associated with neuroendocrine activation (cortisol response), altered sleep (electroencephalography changes), immune imbalance (reduced T-lymphocyte proliferation), inflammatory cell mobilization (neutrophils), and prothrombotic response (platelet activation and increased vWF-ag) as well as hemodynamic changes (heart rate and blood pressure), especially in the early months following loss. Additional evidence suggests that bereavement interventions have the potential to be of value in instances where sleep disturbance becomes a prolonged feature of complicated grief, but have limited efficacy in maintaining immune function in the normal course of bereavement.     

Narrative Matters: A Monster Calls – a portrayal of dissociation in childhood bereavement

‘A Monster Calls’ is a children's fantasy novel written by Patrick Ness, based on an original idea by Siobhan David. Released to critical acclaim, the novel was lauded on its dealing of complex issues relating to bereavement and grief in a manner accessible to its younger readers. This article explores how ‘A Monster Calls’ presents a portrayal of a dissociative child in response to bereavement, and what impact this portrayal may have on the novel's younger readership.     

Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey

CONTEXT: Symptoms of intense bereavement-related sadness may resemble those of major depressive disorder (MDD) but may not indicate a mental disorder. To avert false-positive diagnoses, DSM criteria for MDD exclude uncomplicated bereavement of brief duration and modest severity. However, the DSM does not similarly exempt depressive reactions to other losses, even when they are uncomplicated in duration and severity. OBJECTIVE: To test the validity of the DSM exclusion of uncomplicated depressive symptoms only in response to bereavement but not in response to other losses. DESIGN: Community-based epidemiological study. PARTICIPANTS: From the National Comorbidity Survey (NCS) of 8098 persons aged 15 to 54 years representative of the US population, we identified individuals who met MDD symptom criteria and whose MDD episodes were triggered by either bereavement (n = 157) or other loss (n = 710). Intervention We divided the bereavement and other loss trigger groups into uncomplicated and complicated cases by applying the NCS algorithm for uncomplicated bereavement to the reactions to other losses. We then compared uncomplicated bereavement and uncomplicated reactions to other losses on a variety of disorder indicators and symptoms. MAIN OUTCOME MEASURES: Nine disorder indicators, as follows: number of symptoms, melancholic depression, suicide attempt, duration of symptoms, interference with life, recurrence, and 3 service use variables. RESULTS: Episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators. Moreover, uncomplicated reactions, whether triggered by bereavement or other loss, are significantly lower than complicated reactions on almost all disorder indicators. CONCLUSION: The NCS data do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses from MDD diagnosis.     

Support for bereaved owners of pets

TOPIC: The bond that exists between people and their pets and its impact on physical and mental health. PURPOSE: To review the current literature and explore the clinical implications of bereavement related to pets. SOURCES: A comprehensive review of the bereavement, veterinarian, and agricultural literature related to attitudes and response patterns to pet and animal death. CONCLUSIONS: The death or loss of a beloved pet can be a life-changing event.     

Grief education and bereavement support in Japan

Abstract This paper introduces the activities of the Japanese Association for Death Education and Grief Counseling, highlighting especially its grief education and bereavement support program. Because of greater life expectancy, most women in Japan will one day experience the death of their husbands, therefore pre-widowhood education programs are offered to married women in order to prepare them for widowhood. Memorial services, Buddhist, Christian and non-religious, are offered for bereaved persons. The search for a new self-identity after bereavement, the role of volunteer work, and the search for meaning in loss and bereavement are discussed. The issues of disenfranchised grief and grief after death from overwork are important themes in grief education.     

Late-life bereavement and complicated grief: a proposed comprehensive framework

Objectives: The construct of complicated grief (CG) has garnered increased empirical attention since it has been proposed as a diagnostic category for the upcoming Diagnostic and Statistical Manual of Mental Disorders-V. The aim of this article is to critically examine construct validity in light of a proposed conceptual framework, with special emphasis on understanding late-life bereavement.

Method: This is a review article that critically examined current bereavement and grief models. We explored discriminant and convergent validity between CG and uncomplicated grief (UG) and other psychopathological constructs in terms of symptom intensity, symptom trajectories, bereavement outcomes, and treatment response.

Results: The findings from this review show mixed support for differentiating CG from other outcomes of bereavement for the following reasons: (1) a clear boundary between CG and UG has not been adequately supported, (2) symptoms of CG and bereavement-related depression and anxiety overlap, although there is some evidence of incremental validity in that CG symptoms predict global functioning above and beyond symptoms of depression, and (3) the treatment literature demonstrated that general grief interventions and treatment targeted for improving depression are ineffective at treating symptoms of CG, whereas interventions specially tailored to treating CG have been moderately effective. The findings also emphasize the importance of considering pre-bereavement circumstances, such as preexisting depression, in the conceptualization of broader bereavement outcome.

Conclusion: There were mixed findings supporting the construct validation of CG. A comprehensive framework that emphasizes pre-bereavement circumstances was proposed in order to better predict various grief trajectories and outcomes of late-life loss.