Review articleComplicated grief: Knowledge, attitudes, skills and training of mental health professionals: A systematic review
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.
Section snippets
Search strategy
A systematic search of the published literature was undertaken using a number of electronic databases in order to maximise the identification of relevant studies. Databases searched included PsychInfo, Embase, Medline, CINAHL, PBSC, Web of Science and ERIC. The reference lists of all retrieved and potentially relevant articles and reviews were hand-searched for additional studies. In advance of carrying out the search, to ensure that it was as rigorous and comprehensive as possible, the
Search results/Included studies
The electronic search of the various databases yielded a total of 305 articles and all results were exported to Endnote. Following the process in Fig. 1, 20 papers were selected for full text review. The references of all the papers were hand searched for relevance [31] but no additional papers were included.
Description of eligible papers/Study characteristics
Of the 20 papers included, six examined primary data and of the remaining 14 publications nine were reviews or overviews presenting guidelines for clinicians from various specialties
Discussion
As far as can be ascertained, this is the first systematic review to examine the knowledge, attitudes, skills and training of mental health professionals with respect to complicated grief. The aim of the review was to establish the nature and content of primary research in this area and also to examine the recommendations of CG researchers regarding these four areas in the care of people with CG. The fact that only 20 papers which met the inclusion criteria were identified, from a search of
Conflicts of interest
None to declare.
Funding
This work was supported by the Irish Hospice Foundation through the awarding of the Thérèse Brady Scholarship to Anne Dodd.
Author contributions
AD is completing a PhD on the topic under the supervision of SG, PD and SD. AD developed the methodology with direct input from SG, PD and SD. AD conducted the search described and gathered the records. All authors contributed to the analysis of the data. AD drafted the paper and SG, PD and SD provided comments. All authors have made substantial contributions to the three areas identified and have approved the final article. SD is an employee of the funder and served as an independent
Acknowledgements
The authors wish to thank Orla Keegan, Head of Education, Research and Bereavement Services at the Irish Hospice Foundation, Dublin, Ireland and Honorary Senior Lecturer at the Royal College of Surgeons in Ireland for her support of the project and her comments on a pre-submission draft of the paper.
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