Introduction
Grief is a natural response to the loss of a loved one, and for most people this grief abates over time. There is no evidence to suggest that routine intervention for uncomplicated grief is either warranted or useful (Parkes Reference Parkes1998; Schut & Stroebe Reference Schut and Stroebe2005). However, it is estimated that approximately 10% of people develop complications in their grieving process (Lundorff et al. Reference Lundorff, Holmgren and Zachariae2017). These people continue to experience intense yearning for the deceased person, often accompanied by functional impairment (Rosner et al. Reference Rosner, Pfoh and Kotoucˇová2011), impaired health and increased risk of mortality (Stroebe et al. Reference Stroebe, Schut and Stroebe2007). Such a grief response is variously named as complicated grief, persistent complicated bereavement disorder and prolonged grief disorder and there is much evidence to suggest that it can benefit from professional intervention (Shear et al. Reference Shear, Frank, Houck and Reynolds2005; Wagner et al. Reference Wagner, Knaevelsrud and Maercker2006; Rosner et al. Reference Rosner, Bartl and Pfoh2015; Boelen Reference Boelen2016).
Some bereaved people may be reluctant to seek help from professionals, including their general practitioner (GP), for fear of their grief being medicalised (Nic an Fhailí et al. Reference Nic an Fhailí, Flynn and Dowling2016). Similarly, GPs may be equally fearful about medicalising a normal life event (Nagraj & Barclay Reference Nagraj and Barclay2011). However, for many bereaved people, the GP is the first port-of-call for support (Bergman & Haley Reference Bergman and Haley2009; Ollerenshaw Reference Ollerenshaw2009; Ghesquiere et al. Reference Ghesquiere, Shear and Duan2013) and in this context, GPs have been identified as an accessible and affordable source of support (Clark et al. Reference Clark, Marley and Hiller2006). A systematic review examining professionals’ engagement with complicated grief found that GPs held ‘gatekeeper status’ (p. 1454; Dodd et al. Reference Dodd, Guerin, Delaney and Dodd2017). GPs often have prior knowledge of the bereaved person and their family history, so the role they play in the person’s bereavement care is vital (O’Connor & Breen Reference O’Connor and Breen2014). GPs are therefore perfectly positioned to provide patients with the necessary support for grief-related issues (McGrath et al. Reference McGrath, Holewa and McNaught2010). In Ireland, access to general practice and health services is means tested, and if deemed eligible, and individual is entitled to free GP access only, or free GP and general health services depending on level of assessed income of the individual. A study of youth mental health in Ireland found that GPs were the most likely source of formal support and the primary access point (Dooley & Fitzgerald Reference Dooley and Fitzgerald2012). Also, in Ireland the National Office for Suicide Prevention recommends engaging with one’s GP as the first step in help-seeking following bereavement (2016).
However, despite their role in bereavement care, research suggests that GP training in this area is limited (Charlton & Dolman Reference Charlton and Dolman1995; Lloyd-Williams & Lloyd-Williams Reference Lloyd-Williams and Lloyd-Williams1996; Low et al. Reference Low, Cloherty and Wilkinson2006). The UK survey by Lloyd-Williams found that only 30% of GPs had received training on grief and, of that 30% most of them found their training to be inadequate. A more recent study by O’Connor and Breen Reference O’Connor and Breen(2014) highlights that GPs lack clarity and consistency on how to approach bereavement care. A systematic review on bereavement care in primary care found it to be ‘frequently overlooked in clinical practice and largely ignored in the primary care scientific community’ (Nagraj & Barclay Reference Nagraj and Barclay2011, p. e47). Consequently, those in need of intervention in their grieving process may not receive the help they need (Ghesquier et al. Reference Ghesquiere, Patel, Kaplan and Bruce2014). In the Irish context, the issue of grief, including awareness of ‘normal and abnormal grieving processes’, is included in the end of life module of the GP curriculum (Irish College of General Practitioners [ICGP] 2019, p. 208). However, this is a small part of a very broad curriculum. Additionally, the Irish Hospice Foundation runs specific courses for relevant clinicians in the assessment and treatment of complicated grief. Looking to other countries, the ICGP curriculum is similar to the Royal College of General Practitioners (2019; https://www.rcgp.org.uk/training-exams/training/gp-curriculum-overview.aspx) curriculum for GPs in training. The Royal Australian College of General Practice curriculum for trainee GPs deals with grief and bereavement in a more comprehensive manner, with specific skills development for the assessment and treatment of complicated grief (RACGP 2016; https://www.racgp.org.au/education/education-providers/curriculum/2016-curriculum).
Acknowledging that most people do not require professional intervention in their grieving process and taking account of the pivotal position of the GP in the provision of care following bereavement, the aim of this study was to investigate knowledge of and engagement with complicated grief in a sample of GPs working in Ireland.
Method
Design
This qualitative study adopted a phenomenological approach to explore GPs’ knowledge of and practice regarding complicated grief. The design and implementation of the study was influenced by O’Brien et al. (Reference O’Brien, Harris and Beckman2014) reporting standards. The research was conducted in the context of a larger funded study on the knowledge, attitudes, skills and training regarding complicated grief among mental health professionals. The researchers on the main study were a psychotherapist, a clinical psychologist, a psychiatrist (representing the target groups for the main study) and an academic researcher. This complementary element was developed by the team and implemented by a postgraduate psychology student as part of their degree. While the student did not have professional experience of the issue of complicated grief, they were supported in conducting the research by an experienced team.
Participants
The target population was GPs working in the greater Dublin area in Ireland, who were willing to take part in an interview regarding complicated grief. While it was initially planned to contact potential participants based on publicly available contact information in one area of Dublin, this proved to be unsuccessful and a purposive approach drawing on snowball sampling was added, with participating GPs asked to recommend the research to peers. As a result, nine GPs (five men) agreed to participate, reflecting the gender patterns reported in a survey of GPs in Ireland (Kelly et al. Reference Kelly, Teljeur, O’Kelly, Ni Shuilleabhain and O’Dowd2019). Two of the GPs worked in rural areas of Ireland, with the rest working in urban areas. This regional breakdown is somewhat different to the patterns reported by O’Kelly et al., though differences in the classifications of the two studies prevent a direct comparison. To ensure confidentiality only limited demographic information was recorded and so no other details are available.
Data collection
Data were collected via semi-structured interviews. Noting that GPs were not likely to be in a position to take part in an in-depth interview, the focus was on the issue of complicated grief rather than the wider context of typical grief and related difficulties. The topic guide drew heavily on the materials from the wider study, which was influenced by the findings from a systematic literature review (Dodd et al. Reference Dodd, Guerin, Delaney and Dodd2017). The topic guide focussed on knowledge of complicated grief and the steps taken to identify and provide the patient with the necessary assistance. It investigated their familiarity with relevant research as well as their knowledge of the debate on inclusion of complicated grief in DSM-5 (American Psychiatric Association 2013), their previous training in the area and their interest in participating in future training in complicated grief. While the inclusion of DSM-5 might be less directly relevant to GPs, this was an important aspect of the wider study and also central to the study given the inclusion of prolonged grief-related disorder (a form of complicated grief) in DSM.
Procedure
Ethical approval was received from University College Dublin and the Irish College for General Practitioners. GPs were provided with information sheets and consent forms. The interviews occurred in the workplace or another convenient location. Interviews were audio recorded, transcribed and checked for accuracy.
Analysis
A thematic analysis was carried out (Braun & Clarke Reference Braun and Clarke2006), which began with an initial reading and re-reading of each transcript. Codes were created from the transcripts, and then collapsed into categories to identify the emerging themes. For example, ‘no protocol’ ‘intuition’ and ‘using mind’ were collapsed together to form the theme ‘no clear guidance’. A credibility check was carried out, by which two members of the research team developed candidate themes independently and met to discuss their interpretation of the data. Based on this discussion, more inclusive and objective themes were developed by reviewing, combining and collapsing the themes.
Results
The findings considered aspects of GPs’ knowledge of complicated grief and their experience and views of practice. Figure 1 presents an overview of the topics examined and themes discussed by participants as they relate to the aims of the study.
Fig. 1. Overview of core topics and related themes.
Participants discussed their lack of knowledge regarding the identification of complicated grief. The GPs reported that they had no clear guidelines on aspects of grief and bereavement. They reported using their ‘own mind’ (GP3), their ‘intuition’ (GP4) while another stated that he did ‘not have a protocol that I will go to. You know I would base it I on my, I suppose, experience’ (GP9).
Participants reported having to use their experience and intuition to create a categorisation of grief in order to determine the type of intervention needed. One GP reported ‘dividing them into mild moderate or severe’ grief (GP1). Another based his identification on whether the grief response was what he termed a ‘kind of a reactive grief’ (GP8) or he looked for ‘clinical symptoms’. Some GPs used the duration of grief as a means of categorisation, indicating that if the patient was still ‘not functioning after about six months I would have the alarm bells up’ (GP4).
All participants reported limited previous awareness of complicated grief and the research into it. As a result, they had no previous knowledge of the debate regarding whether complicated grief should be included in DSM. However, some did express an opinion about the inclusion of complicated grief in DSM. Two GPs supported its inclusion, with one stating; ‘I think it can be beneficial to have a label and then have an appropriate intervention which is often one of the difficulties (GP4). One GP was opposed to the inclusion of complicated grief in diagnostic manuals and stated that ‘I think medicalisation of grief is a mistake…. It is like medicalising happiness’ (GP3) and further stated that the medicalisation of grief will ‘suit the drug companies and it will suit the psychiatric profession’.
All the GPs stated that they had no training in complicated grief. Some referred to their outdated exposure to grief issues during their undergraduate training which in some cases was some time ago. Many GPs interviewed expressed interest in training in complicated grief, ‘Yeah probably I would’ (GP8), stating that they wanted the training to be ‘nice and accessible and easy’ (GP9). However, two stated personal reasons for not being interested in the training. One of these stated ‘I am not going for any exams again, I’m not going for any course. I’ve had enough’ (GP5).
In terms of practice regarding complicated grief, topics included consultation, intervention, referral and review. All GPs agreed that the initial consultation was central in deciding how, or if, to intervene. The majority explicitly described processes for consultation, including that they would ‘talk to them’ (GP9) and ‘take a full and complete history’ (GP6). During the consultation, the GPs queried the support available to the patient and the support required by the patient from the GP. In situations where the grief did not prompt undue clinical concern, they encouraged the patient ‘to look to their family and friends for support’ (GP8). Also, in some cases the GP himself assumed the ‘supportive role’ (GP9) or provided the person with ‘sick leave’ or ‘see if they need a home help or [assistance]’ (GP5).
There was broad agreement among the GPs regarding the need for intervention if the ‘patient is an immediate danger to himself or to others’ (GP2) or ‘if there’s any issue of committing suicide’ (GP6). The presence of depression was also an important means of categorising the person’s grief response. GPs were of the view that intervention was warranted ‘if it becomes severe and it becomes depression’ (GP1) and ‘if there’s actually maybe elements of clinical depression present’ (GP3). The GPs also differed in their attitudes to the use of medication. Some GPs described routinely using medications, prescribing ‘relaxing tablets’ (GP5) and ‘antidepressants for a short period of time’ (GP1). However, one GP expressed a strong opinion against the prescription of medication as ‘I don’t think they work…. I think they cause addiction… Putting patient on anxiolytics causes added complications’ (GP3). Two other GPs, though open to medication as a resource, did not routinely use it, stating that they would try other forms of treatment before using medication.
When the presenting behaviour was of clinical concern the GPs were in agreement regarding the importance of referring the patient to the necessary support . One GP encapsulated this sentiment stating that ‘my role as a GP is to suss out those patients who need emergency help now and those who don’t’ (GP2). However, access to service was a concern when making a referral and presented a challenge to the GPs. In some cases, access to service was dependent on the situation of the GP. For example, one participant’s practice (GP9) was attached to a setting which offered counselling services. The GP was able to ensure that their patients’ ‘[work] life doesn’t fall apart’ and could direct them ‘towards assistance funds and to their [related] advisor services’ (GP9). This GP also acknowledged that the other GPs would not have this level of access. The remaining GPs corroborated this when they described access to specialist services as ‘impossible’ (GP1), describing how they had ‘to ring around like crazy to find a suitable place for this patient’ (GP6).
Participants differed on their attitude towards reviewing patients once they had been referred onwards. Many GPs suggested that the appropriate response to grief-related issues would be to ‘see them at least within two weeks’ (GP8) while two stated that after the patient was referred there was ‘no longer a need to [engage]’ (GP2).
Discussion
The aim of this research was to explore GPs’ current knowledge of complicated grief and their practice in relation to it. The GPs had no previous knowledge of complicated grief as a concept and the identification of a grief response that required intervention appeared to be based on intuition and experience. Despite a lack of knowledge, the GPs in this study did describe some of their preferred practices and stressed the importance of the initial consultation. The GPs were in agreement about the appropriateness of referral to another agency or professional. However, access to services was seen as an issue, given its variability depending on location and context. In terms of training in complicated grief, all the GPs reported either having no training or described training that was outdated. This is likely to leave them ill-equipped to identify complicated grief and provide appropriate support. GPs expressed an interest in training but also stressed that this training needed to be readily accessible due to time limitations.
The research literature suggests that the use of a standardised instrument to identify complicated grief is important so that it is not wrongly classified as depression (Dodd et al. Reference Dodd, Guerin, Delaney and Dodd2017). One such time-efficient instrument which might be employed is the Brief Grief Questionnaire (Shear et al. Reference Shear, Jackson and Essock2006), which has been recommended for use in healthcare settings (Simon Reference Simon2013). Given the reliance on experience in decision-making about interventions, and in the absence of clear guidelines as to what constitutes complicated grief, it is likely that there will be variation in what classifies as a severe grief reaction. With the need for training highlighted, this might include the use of a standardised tool for identifying complicated grief, thus reducing the reliance on intuition and experience evident in this study.
In providing support the ‘ “goodness of fit” between donor activities and the needs of recipients’ (p. 176; Vachon & Stylianos Reference Vachon and Stylianos1988) is crucial and, since the GP frequently has a knowledge of the person and the family, s/he is well placed to assess the quality of this fit. They may also be well-placed to take account of the important cultural and gender dimensions of support (Nurullah Reference Nurullah2012). The GPs’ view regarding the appropriateness of referral to another agency reflects published perspectives, where they report their role as both a service provider and a ‘broker of services’ (O’Connor & Breen Reference O’Connor and Breen2014). However, in the absence of a clear referral pathway it is likely that some patients will be referred to private counsellors and access to this service, for the most part, is predicated on ability to pay, thereby creating a discrimination against those from more socially deprived backgrounds (Wiles et al. Reference Wiles, Jarrett, Payne and Field2002). Of those who expressed an opinion, two GPs thought that the inclusion of complicated grief in diagnostic manuals would increase the patient’s access to appropriate help.
The review of professionals’ knowledge, attitudes, skills and training in relation to complicated grief by Dodd et al. (Reference Dodd, Guerin, Delaney and Dodd2017) reported the necessity for proactive follow-up on the part of the clinician, thus lessening the onus on the bereaved person. There is empirical evidence to suggest that bereaved persons most in need of services are the most reluctant to seek help (Lichtenthal et al. Reference Lichtenthal, Nilsson and Kissane2011) and so a proactive approach on the part of the clinician ensures that people will not go unrecognised. In the current study, while some of the GPs said that they would follow-up where there had been a referral, there was no suggestion that follow-up was routine. Main (Reference Main2000) suggests that ongoing bereavement awareness of the part of the GP could be facilitated by recording the issue in patient notes.
Strengths and limitations
While the main limitation of this research is that it is a small exploratory study, its value as an initial exploration is important, given there has been limited research on GPs’ knowledge and practice regarding complicated grief in Ireland. There were significant challenges in identifying a suitable sample, but this could possibly be explained by GPs’ lack of familiarity with the research and a resulting unwillingness to participate. While the aim of qualitative research is not to generalise from a sample to a population in the traditional sense of the word, it is in a position to identify views that may be reflected in wider groups that are similar to the sample secured. We have no reason to believe that participants in this study differ from many GPs in Ireland, though we have reported limited demographics to prevent possible identification of participants. Nevertheless, it is important to note that snowball sampling can create a level of homogeneity in a sample. Despite this limitation, the study is strengthened by use of the O’Brien et al. (Reference O’Brien, Harris and Beckman2014) guidelines to inform the design and implementation of the study and by the rigour of the analysis conducted. A credibility check was carried out where two researchers identified and compared themes in a section of the text to avoid potential bias in the analysis.
Implications
General practitioners in Ireland, similar to physicians in earlier research, do not have extensive knowledge of complicated grief. However, their interest in training suggests a willingness to engage with their patients’ grief issues. Taking account of the gatekeeper status of the GP in relation to bereavement services, training tailored to the needs of the GP would appear to be warranted. Such training might address the dual role held by general practitioners as both bereavement service providers and brokers of the service. Ideally, training in assessing differences in usual grief experiences compared to complicated grief would be initially developed as part of a GP training experience. More comprehensive assessment skills and possible treatment strategies may be more appropriate at postgraduate level, as reflected, for example, in the progressive Daffodil Standards, developed by the Royal College of General Practitioners (see https://www.rcgp.org.uk/daffodilstandards,Standard 7, Care after death). Recognising the scale of the present study, further research adopting a quantitative approach could examine these issues on a wider sample, allowing for examination of the factors that may influence GPs’ experiences in relation to complicated grief.
Acknowledgements
We are grateful to the participants in the study for their support for the research.
Conflicts of interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval for this study was granted by the Irish College of General Practitioners and the UCD School of Psychology Taught Masters Research Ethics Committee.
Financial Support
None to this study, main project funded by the Irish Hospice Foundation.
