Grief, Loss, and Bereavement Support
Normal grief
Grief is not a linear sequence of stages; the stage model is a teaching metaphor that questions penalize when applied rigidly. Normal grief oscillates - the dual-process model describes moving between loss-oriented (crying, reviewing, yearning) and restoration-oriented (tasks, roles, distraction) coping. Anticipatory grief occurs before the death and does not necessarily reduce post-death grief. Continuing bonds - talking to the deceased, keeping rituals - is adaptive, not pathologic.
When grief becomes disorder
DSM-5-TR prolonged grief disorder requires persistent yearning or preoccupation plus associated symptoms causing impairment at 12 months in adults (6 months in children and adolescents); ICD-11 uses a 6-month threshold. Distinguish it from major depression (pervasive anhedonia, worthlessness, global loss of interest) and from disenfranchised grief, which arises when a loss is not socially recognized - a secret partner, a pet, a perinatal death, an estranged relationship.
Bereavement support
Hospice must offer bereavement services for up to a year after death, with risk assessment at intake and after death. Risk factors include prior psychiatric history, dependent relationship, sudden or violent death, multiple concurrent losses, poor social support, and financial strain. Universal support (mailings, memorials), selective support (groups, pastoral care), and indicated support (individual or specialized therapy) form a stepped model - not everyone needs therapy. Screen staff for compassion fatigue and moral distress.
Traps
Assuming a family is 'doing well' because they are not crying; offering intensive therapy universally; labeling continuing bonds as pathology; ignoring the grief of the team.
Rule of thumb. Ask 'who is this person to you, and who else knows about this loss?' to surface both attachment and disenfranchisement.