A new understanding of the biopsychosocial impact of the death of a loved one has focused the grief-counseling field on identifying and treating people at risk for mental and physical complications as a result of their loss. Rather than using a one-size-fits-all approach to bereavement, like assuming all people will need the same amount of treatment, psychologists need to employ careful assessment and tailored treatments, according to a report produced by members of APA's Ad Hoc Committee on End-of-Life Issues and published in Professional Psychology: Research and Practice (Vol. 34, No. 6) in December.

Most bereaved men and women cope effectively, says ad hoc committee member Robert Neimeyer, PhD, of the University of Memphis, but research has shown that the stresses associated with profound loss, such as living alone and confronting death, can have a serious--even deadly--impact on a sizable minority. The work of the ad hoc committee prompted the report to identify roles for psychologists in end-of-life care, Neimeyer says.

Indeed, the report cites research by psychiatrist Selby Jacobs, MD, PhD, of Yale University, that shows 40 percent of people who lose a spouse experience generalized anxiety or panic syndromes in the first year. And psychiatrist Colin Murray Parkes, MD, formerly of the London Hospital Medical College, has found that mortality among surviving spouses in the six months following a loss increases 40 to 70 percent compared with the general population.

Of particular concern, says Neimeyer, is the finding by Yale University psychologist Holly Prigerson, PhD, that roughly 15 percent of people who've lost a loved one might be susceptible to "complicated grief," a condition more severe than the average loss-related life transition, depression and anxiety. Distinguishable from depression and anxiety, it is marked by broad changes to all personal relationships, a sense of meaninglessness, a prolonged yearning or searching for the deceased and a sense of rupture in personal beliefs.

In light of that new understanding, psychological researchers and practitioners are working to develop new ways to assess and treat severe grief that take into account a broader sense of how grief manifests itself; individual differences in the grief experience require custom-tailoring of treatment plans, Neimeyer says.

Evolution in assessment

One group of researchers, for example, is examining factors that identify people at risk for complicated grief, Neimeyer says. The researchers are objectively assessing risk factors by reviewing the circumstances surrounding deaths.

Chronic and unremitting grief is typically associated with sudden, unexpected and traumatic death, the loss of children or young people, and the relative closeness of the bereaved person to the deceased, the report says. Particular risk factors include excessive dependency in the relationship with the decedent or a history of mental illnesses such as depression in the bereaved, Neimeyer says.

In the past, the mental health community defined varying reactions to grief, such as delayed onset of grief, as disorders, Neimeyer says. In particular, people who grieved in ways uncharacteristic for their cultural background were labeled as disordered.

But new research and a growing understanding of grief has prompted psychologists to use different diagnostic factors for complicated grief, such as changed relationships with family and friends, feelings of meaninglessness and ruptured beliefs, which are more apt to spur health-threatening grief, he adds.

In fact, says Neimeyer, the American Psychiatric Association has formed a panel of experts under Prigerson to consider including "complicated grief" in the next version of the Diagnostic and Statistical Manual of Mental Disorders.

Revolution in treatment

In addition to recommending changes in the way severe grief is diagnosed, the ad-hoc committee has highlighted improved methods for treating grief, Neimeyer says.

For example, the widely held assumption that grieving requires "letting go" is being questioned, Neimeyer says.

Instead of gaining closure or trying to say goodbye, the goal of grief counseling should be to foster a constructive continuing bond with a deceased person, he says. This can be accomplished through remembering the good times, setting up an internal dialogue with a lost loved one, continuing to think of that person on a regular basis and imagining the person's reactions to current life events and problems, he says.

In the immediate aftermath of the death, the bereaved struggling with grief-related symptoms may benefit from coaching in symptom-management techniques, such as relaxation skills and thought-stopping, according to research by psychologist Donald Meichenbaum, PhD, of the University of Waterloo in Canada.

However, Neimeyer cautions against an exclusive focus on negative emotion because research by psychologists like George Bonanno, PhD, of Columbia University, and Camille Wortman, PhD, of the State University of New York at Stony Brook, suggests that signs of resourcefulness, such as the expression of positive emotion and the ability to find meaning in the loss, may be better predictors of long-term outcome.

"There's a great deal of good that can come from finding the silver lining in loss and from fully experiencing the process" of grieving, says Neimeyer. "The bereaved can be far more empowered than we've previously believed."

With that in mind, contemporary grief research is focusing on the subset of grievers who show remarkable resilience even after losing a spouse, Neimeyer adds.

"Understanding how it is that these people are successful in coping with loss and developing constructive methods for continuing their lives will help psychologists guide those who are more likely to struggle."