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

Highlights

• Considerable variation in the methodological quality of the literature reviewed.

• Sufficient agreement exists among researchers regarding assisting someone with CG.

• The fear of medicalising grief may be based on conflation of normal grief and CG.

• Attitudinal barriers to implementation of research need particular attention.

• Urgent need to engage with the translation of CG research into clinical practice.

Abstract

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.

Introduction

Although grief can be intensely painful, most people navigate it successfully and manage to assimilate their loss and adjust to life in their changed world, with the support of their family and friends, without professional intervention [1], [2]. However, for a significant minority of bereaved people [3], grief does not abate despite the passage of time and they develop complicated grief (CG). CG refers to a prolonged state of grief and indicates an inability of the person to integrate the death into his or her life. CG is characterised by a constant yearning and searching for the deceased, persistent thoughts of the deceased and intense and painful emotions [4]. The intensity of the grief prohibits the person from regaining or even approaching the pre-loss state of social functioning, is associated with increased risk of mortality [5] and with serious health consequences [6]. While there is not yet agreement on the nomenclature for such grief it is widely accepted that it exists as a distinct disorder [7], [8] and as one which responds to targeted treatments [9], [10], [11], [12], [13], [14]. It has been included in the DSM-5 as Persistent Complex Bereavement Disorder, in the emerging measures and models section, as a condition requiring further study [15].

The integration of mental health research findings into everyday clinical practice is slow with a time-lag of 15–20 years being commonly cited [16]. Despite the abundance of research into CG, somewhat less attention has been given to the extent to which these research findings are translating into the routine practice of mental health professionals. In a study involving members of the American Association of Marriage and Family Therapists, Stephenson [17] found that 90% of therapists reported feeling competent to provide grief counselling despite having received little or no training in the area. Since then, various other studies of health professionals report that death education on professional courses was addressed, not as a stand-alone course, but as an infusion into other areas of course work [18], [19], [20], [21], [22]. A study of psychology departments of 161 US colleges, found that 80% had not offered a course on death education in the five years prior to completing the survey [23]. Ober, Granello, and Wheaton [24] confirmed the results of Charkow [20] that counsellors, by and large, perceive themselves to be well prepared from a personal perspective to work with grieving clients but much less prepared when considering professional grief-specific knowledge and skills. A national survey of US hospices [25] found that 50% of them were screening patients for CG and for access to therapy while the European Association for Palliative Care bereavement care taskforce [26] found that only 25% of the services surveyed described using a formal risk assessment tool. The aim of this systematic review is to establish both the recommendations of CG researchers regarding the knowledge, attitudes, skills and training they believe relevant to mental health professionals and also to examine how practitioners actually work with CG in clinical practice.