‘Feeling disconnected’ – risk factors for PGD and themes in grief counselling during the COVID-19 pandemic. A mixed-method study

ABSTRACT

Background: Due to its high death toll and measures to curb the pandemic, COVID-19 has affected grieving experiences and may contribute to risk factors for Prolonged Grief Disorder (PGD). Persons at risk for PGD often seek support from grief counselling.

Objective: To explore whether pandemic-associated risk factors have become more important topics in counselling in a mixed-method design.

Method: German grief counsellors (n = 93) rated whether pre-defined risk factors had become more important in grief counselling and indicated additional important themes in an open format.

Results: The counsellors indicated that all pre-defined risk factors had become more important, though differing significantly in their frequency. Most frequently endorsed risk factors were lack of social support, limited possibilities to accompany a dying loved one and absence of traditional grief rituals. Qualitative analysis identified three additional themes: the societal impact of the pandemic, its impact on bereavement support and health care, and a chance for personal growth.

Conclusions: The pandemic has affected bereavement experiences and grief counselling. Counsellors should monitor grief processes and specific risk factors to provide the best possible care for bereaved people when needed.

HIGHLIGHTS

• Pandemic-associated risk factors for PGD have become more important topics in grief counselling during COVID-19.

• Risk factors include especially a lack of social support, limited possibility to accompany a dying significant other and absence of traditional grief rituals.

• Future research is needed to investigate whether monitoring and addressing these risk factors can improve bereavement care.

Antecedentes: Debido al alto número de muertes y las medidas para frenar la pandemia COVID-19, se han interferido las experiencias de duelo y esto puede contribuir a los factores de riesgo del trastorno de duelo prolongado (TDP). Las personas en riesgo de TDP a menudo buscan apoyo en la consejería de duelo.

Objetivo: Explorar si los factores de riesgo asociados con la pandemia se han convertido en temas más importantes en el asesoramiento, en un diseño de método mixto.

Método: Los consejeros de duelo alemanes (n = 93) calificaron si los factores de riesgo predefinidos se habían vuelto más importantes en el asesoramiento de duelo e indicaron temas importantes adicionales en un formato abierto.

Resultados: Los consejeros indicaron que todos los factores de riesgo predefinidos se habían vuelto más importantes, aunque diferían significativamente en su frecuencia. Los factores de riesgo más frecuentemente reportados fueron la falta de apoyo social, las limitadas posibilidades de acompañar a un ser querido moribundo y la ausencia de rituales de duelo tradicionales. El análisis cualitativo identificó tres temas adicionales: el impacto social de la pandemia, su impacto en el apoyo al duelo y la atención médica y una oportunidad de crecimiento personal.

Conclusiones: La pandemia ha afectado las experiencias de duelo y la consejería de duelo. Los consejeros deben monitorear los procesos de duelo y los factores de riesgo específicos para brindar la mejor atención posible a las personas en duelo cuando sea necesario.

背景：由于其高死亡人数和遏制疫情的措施，COVID-19 影响了哀伤经历，可能促成延长哀伤障碍 (PGD) 的风险因素。PGD 风险人群通常会寻求哀伤咨询的支持。

目的：在一项混合方法设计中探究疫情相关风险因素是否已成为咨询中更重要的主题。

方法：德国哀伤咨询师 (n=93) 评估了预定义的风险因素是否在哀伤咨询中变得更加重要，并以开放的形式指出了其他重要主题。

结果：咨询师表示，所有预先定义的风险因素都变得更加重要，尽管它们的频率存在显著差异。 最常见的风险因素是缺乏社会支持、陪伴垂死亲人的可能性受限以及缺乏传统的哀伤仪式。 定性分析确定了另外三个主题：疫情的社会影响、其对丧亲支持和医疗保健的影响，以及个人成长的机会。

结论：疫情影响了丧亲经历和哀伤咨询。咨询师应监测哀伤处理和特定风险因素，以便在需要时为丧亲者提供尽可能最好的护理。

KEYWORDS:

• Grief counseling
• bereavement support
• prolonged grief disorder
• risk factors
• COVID-19 pandemic

PALABRAS CLAVE:

• Consejería de duelo
• apoyo de duelo
• trastorno de duelo prolongado
• factores de riesgo
• pandemia de COVID-19

关键词:

• 哀伤咨询
• 丧亲支持
• 延长哀伤障碍
• 风险因素
• COVID-19 疫情

1. Introduction

The death of a loved one is a stressful life event (Stroebe et al., 2007). While the majority of the bereaved adapt to their loss without professional help (about 60%), the remainder may require some form of psychosocial support and a minority experiences persistent and debilitating grief (Aoun et al., 2015; Bonanno et al., 2011). Prolonged Grief Disorder (PGD) according to ICD-11 is characterised by persistent longing for or preoccupation with the deceased and at least one additional symptom of intense emotional pain, which persists for more than six months and causes significant functional impairment (World Health Organization, 2019). Estimates of PGD prevalence in meta-analyses vary from 9.8% (Lundorff et al., 2017) up to 49% among those bereaved by unnatural deaths (Djelantik et al., 2020). This variability highlights the importance of specific risk factors for adaptation to bereavement. Risk factors that have been identified by previous research include among others sudden or unexpected deaths, low social support, low income or other concurrent stressors, feeling that the death was preventable, searching for meaning, and low family functioning (Burke & Neimeyer, 2013; Stroebe et al., 2007; Thomas et al., 2014).

The COVID-19 pandemic has led to 6.5 million deaths worldwide until October 2022 (World Health Organization, 2020), leaving millions of bereaved persons. Additionally, the societal measures to curb the pandemic have put additional strains on bereaved persons, independently of the cause of death. Social distancing, lockdowns and restrictions in hospital visits are likely to affect grieving processes, as manifested in qualitative research (Mortazavi et al., 2021; Torrens-Burton et al., 2022). Grief researchers have argued that some of the implications of the pandemic correspond or contribute to certain previously established risk factors for PGD (Amy and Doka 2021; Diolaiuti et al. 2021; Djelantik et al. 2021; Eisma et al. 2020, 2021; Hamid and Jahangir 2022; Helton et al. 2020; Mayland et al. 2020; Menzies et al. 2020): These include reduced social contacts, restrictions on funerals, the loss of daily routines and distraction, and secondary stressors such as an increase of financial problems. To illustrate, low social support is a long-established risk factor for PGD. The pandemic-specific restrictions on social contact certainly affected perceptions of social support among the bereaved. Thus, this risk factor may have increased in importance during the pandemic. As another example, the absence of traditional grief rituals (such as saying good-bye and burial of the body) can hinder adaptation to bereavement (Castle & Phillips, 2003; Gamino et al., 2000). Even before the pandemic, not all bereaved persons had the chance to participate in such comforting rituals. However, due to the pandemic-specific regulations (e.g. concerning the number of persons attending a funeral), this risk factor is likely to have affected a larger number of the bereaved and to have become more important. Supporting a potential negative effect of the pandemic on grieving processes, studies report more grief-related distress in bereaved samples during COVID-19 both after COVID-19-attributable deaths (Eisma & Tamminga, 2022; Tang & Xiang, 2021) and independently of the cause of death (Breen et al., 2022). Thus, the provision of bereavement care has become more important than ever (Killikelly et al., 2021).

Bereavement care is often conceptualised within a tiered approach (Rumbold & Aoun, 2015). Bereaved persons who experience elevated levels of grief-related distress or multiple risk factors for PGD may require psychosocial support such as grief counselling (Harrop et al., 2021). A scoping review demonstrates that various psychosocial interventions for family bereavement care during COVID-19 have been implemented (Laranjeira et al., 2022). However, the small number of studies (k = 7) precludes definite conclusions about effective intervention concepts. While some interventions are specifically developed in response to COVID-19 (de Leon Corona et al., 2022), others use previously established concepts in facilitating adaptation to bereavement (Yu et al., 2022). Due to the special strains on bereaved persons during COVID-19, interventions may need to be tailored specifically to address pandemic-specific risk factors and needs. As a first step, however, we need to investigate whether these risk factors and needs have actually changed. Preliminary evidence pointing towards changed topics comes from a survey of bereavement care provision in the UK and Ireland during COVID-19 (Pearce et al., 2021). It investigated the pandemic-specific changes in the services that the practitioners perceived. The results highlight especially the importance of restrictions of social contact for the grieving process.

Thus, assessing potential changes in topics in bereavement support during COVID-19 serves a dual purpose. First, it helps to clarify which of the pandemic-associated risk factors for PGD emerge as more important topics in grief counselling and have increased in relevance. Second, identification of these pandemic-associated risk factors and additional themes may help to inform the development or adaption of psychosocial interventions. The purpose of the present study was therefore to investigate the impact of COVID-19 on counselling topics in bereavement support services. Since we were interested in changes in bereavement support, our survey addressed grief counsellors who had been active before and during the pandemic in the provision of bereavement care. We focused on changes in the topics that were addressed during grief counselling using a mixed-methods approach in order to answer the following research questions:

1. Have pandemic-associated risk factors for PGD as identified by previous research (e.g. low social support through loss of social contacts) become more important topics in grief counselling during COVID-19?

2. Are there additional themes that grief counsellors perceive as having become important topics in counselling during COVID-19?

2. Materials and methods

The study was approved by the Institutional Review Board of the Catholic University of Eichstaett-Ingolstadt (049-2021) and conducted via an online survey using the software Qualtrics (Version 2020) from May 2021 to February 2022.

2.1. Procedure

Recruitment took place via mailing lists, grief counselling associations and a consortium on grief counselling established by the Bavarian State Ministry of Family Affairs, Labour and Social Affairs. Grief counsellors were eligible for the survey if they were at least 18 years old, provided informed consent and had counselled at least five bereaved clients before March 2020. The latter criterion ascertained that participants had experience in grief counselling before the COVID-19-pandemic. There was no financial reward for participation. A total of 247 persons visited the survey page, 140 provided informed consent. Data from participants who had completed less than half of the survey items were excluded (n = 44). Included and excluded participants did not differ in age, professional experience and weekly hours of counselling (all p > .20). For the present analysis, only data of participants who worked with adult bereaved persons were used: Since topics of grief counselling in adults and children will differ and the small number of grief counsellors primarily working with children in our sample (n = 3) allowed no separate analysis, this served to ensure the sample homogeneity. Thus, the final sample consisted of 93 participants.

2.2. Participants

Participants were German-speaking grief counsellors. The sample was predominantly female (94.6%) and had a mean age of 55.7 years (±8.9). Nearly half of the sample reported that they worked as full-time grief counsellors (48.4%). Table 1 summarises further demographical data.

Table 1. Demographic and professional characteristics (n = 93).

Sample characteristics	Percent / Mean (SD), Range
Gender
Female	94.6%
Male	5.4%
Diverse	0%
Age (years)	55.7 (8.9), 28–74
Advanced Training in grief counselling or related fields (yes)	93.5%
Professional experience (years)	9.1 (7.1), 0.8–51.5
Personal grief experience (yes)	97.8%
Weekly hours of counselling	7.7 (7.7), 1–39
Employment type
Full-time	48.4%
Part-time	14.0%
Voluntary	37.6%

2.3. Measures

To the best of our knowledge, there is no established questionnaire for pandemic-specific topics in grief counselling. To identify pandemic-associated risk factors that could have become topics in counselling, we conducted an unsystematic literature search via Google Scholar using the key words ‘COVID-19’ and ‘grief’ or ‘prolonged grief disorder’ in December 2020, including original studies, opinion papers and editorials. Thereby, we identified eight pandemic-associated risk factors: 1. Limited possibilities to visit and accompany a dying person (e.g. due to visiting restrictions in hospitals) (Eisma et al., 2020; Hamid & Jahangir, 2020; Mayland et al., 2020), 2. Absence of traditional grief rituals (e.g. due to official restrictions, limited number of attendees at funerals) (Eisma et al., 2020, 2021; Hamid & Jahangir, 2020; Mayland et al., 2020), 3. Traumatic circumstances of the death (e.g. due to COVID-19, unexpected deaths, deaths in intensive care units) (Eisma et al., 2020, 2021; Mayland et al., 2020), 4. Lack of social support (e.g. due to social restrictions) (Eisma et al., 2020, 2021; Hamid & Jahangir, 2020; Helton et al., 2020; Mayland et al., 2020; Menzies et al., 2020), 5. Loss of helpful routines/ distractions or increased concentration on grief (e.g. due to COVID-related circumstances, home office, furlough) (Helton et al., 2020), 6. Additional stressors (e.g. financial problems, uncertainty about the pandemic’s progress) (Eisma et al., 2020, 2021; Helton et al., 2020; Menzies et al., 2020), 7. Shattered assumptions and beliefs about oneself, the environment and the future (e.g. due to experiencing a pandemic, due to a sense of uncontrollability) (Menzies et al., 2020), and 8. Increased death anxiety or confrontation with one’s own mortality (Helton et al., 2020; Menzies et al., 2020). Participants were presented with all pandemic-associated risk factors and asked if they had become a more important topic in their counselling since the beginning of the pandemic (yes/no). As an open-ended question, participants were asked about additional themes that had become important topics in their counselling. This question was the basis for the qualitative analysis.

2.4. Data analysis

The quantitative analysis was conducted with IBM SPSS statistics (Version 25). Descriptive statistics were used for demographic and professional characteristics. To analyse differences in the importance of pandemic-associated risk factors as counselling topics, Cochran’s Q was calculated as an omnibus test, followed by post-hoc Bonferroni-corrected Dunn-tests.

Reporting of the qualitative analysis follows the SRQR criteria (O'Brien et al., 2014). Qualitative data were analysed according to Mayring (2015) using the software MAXQDA 2022. Coding units were all aspects in the open-ended answers. We defined a minimum of two coding units as necessary to form a category. As the answers were provided in writing, no transcription was needed. The category system was developed using both deductive (using the eight literature-based risk factors as categories) and inductive methods. Thus, statements that did not fit the previously established eight categories were categorised inductively. Two authors (CH and NA) performed the content analysis separately. CH has experience in grief research and counselling / psychotherapy. NA is experienced in conducting qualitative research and in clinical practice. The first researcher (CH) read all answers and summarised suitable aspects under the eight literature-based categories. The remaining answers were used to develop new categories. These new categories were summarised in higher-level categories, and abstraction levels were compared to the literature-based categories. The second researcher (NA) read all answers and independently formed categories inductively. The researchers compared their results and resolved differences through discussion.

3. Results

3.1. Quantitative findings

According to the participating grief counsellors, all literature-identified risk factors became more important topics in grief counselling during the pandemic. However, the number of participating counsellors endorsing a specific risk factor differed significantly between the risk factors (Q(7) = 157.18, p < .001, see also Figure 1).

Figure 1. Increased importance of the literature-identified risk factors (ordered by frequency of endorsement).

Nearly all participants indicated that Lack of social support and Limited possibilities to accompany a dying person (both 94.4%) had become a more important topic of grief counselling in the pandemic. Only 37.5% rated Confrontation with one’s own mortality as a more important issue and about half of the participants did so for Shattered assumptions (52.8%). Post hoc comparisons demonstrated significant differences between individual risk factors. The three most frequently endorsed risk factors Lack of social support, Limited possibilities to accompanying a dying person and Absence of traditional grief rituals did not differ from each other (all p > .05). However, these three risk factors were significantly more frequently endorsed as having become more important topics compared with the four least endorsed risk factors (Traumatic circumstances of the death, Additional stressors, Shattered assumptions, and Confrontation with one’s own mortality; all p ≤ .002). Confrontation with one’s own mortality was significantly less frequently endorsed compared with all other risk factors (all p < .001), except Shattered assumptions (p > .05). There were no significant differences in endorsement between the risk factors Loss of helpful routines, Traumatic circumstances of the death, and Additional stressors (all p > .05).

3.2. Qualitative findings

The open-ended question elicited a total of 30 answers for the qualitative analysis. Participants who answered the open-ended question were all female and had a marginally lower professional experience compared to grief counsellors who provided no answer (M_noanswer= 9.9 ± 7.8 years vs. M_answer= 7.6 ± 5.1 years, t(82) = −1.73, p = .09). Participants who provided open-ended answers did not differ significantly from the remaining sample in age, advanced training in grief counselling, personal grief experience, weekly hours of counselling, or importance ratings of the risk factors (all p ≥ .20).

Deductively, the coding units confirmed three pre-identified pandemic-associated risk factors (Lack of social support, Loss of routines, Additional stressors). Inductively, the answers constituted three additional relevant themes: Societal impact of the pandemic, Personal values and priorities, Impact on bereavement support / health care (see Table 2). Though these stressors did not affect only bereaved persons, they may have burdened them differentially in an already difficult time in their lives.

Table 2. Categories and illustrative examples of the qualitative analysis.

Category	Number of coding units allocated (k)	Illustrative examples
1. Lack of social support	10	‘Little physical contact, feeling more disconnected’ (participant 16) ‘Lack of exchange with other bereaved persons, not being able to spend supportive time with other people’ (participant 20) ‘Building and maintaining a functioning social net’ (participant 29)
		‘Social withdrawal because of fear of Corona’ (participant 25)
2. Loss of routines	5	‘Little or no continuation of familiar group experiences (associations, sports groups etc.)’ (participant 16)
		‘Having more time on one’s hands during lockdown to spend on one’s innermost thoughts and feelings’ (participant 11) ‘Being confronted with oneself, because there was less distraction and less social involvement, which in turn created more stress’ (participant 19)
3. Additional stressors	4	‘You cannot make plans when there is no knowing when everything will be back to “normal”’ (participant 23) ‘There is little spontaneity possible for families to share their grief and mourn’ (participant 16)
		‘increasing worries about other family members’ (participant 6)
4. Societal impact of the pandemic	3	‘Many conversations concern the issue that people perceive Corona regulations occasionally as extremely restrictive and partly inconsistent or incomprehensible. Their own everyday experiences do not fit the picture that the media communicate as the present reality. (…)’ (participant 21) ‘The topic “Corona death” has become a public topic. The individual fates remain mostly unseen. Clients describe that the permanent confrontation with this topic is very straining. Corona deaths are just presented as numbers and the people behind these numbers lose their individuality.’ (participant 17)
5. Personal values and priorities	3	‘One’s own contentment and being more humble before life’ (participant 7) ‘Life altogether is considered more critically by the bereaved. What is really important? Do I really need all these things? What is really meaningful? Who are the important people in my life? Who or what can I rely on?’ (participant 29)
6. Impact on bereavement support / health care	5	‘Cancellation of a rehabilitative treatment (hospital does not admit new patients)’ (participant 13) ‘Lack of contact persons, extreme need to talk’ (participant 3)

3.2.1. Lack of social support

Corroborating their quantitative responses, participating grief counsellors mentioned most frequently that aspects of social support had become more relevant in grief counselling during the pandemic. Legal restrictions reduced social contacts universally, often leading to feelings of loneliness. Sometimes, social withdrawal was self-initiated due to fear of a COVID-19 infection. All this resulted in bereaved persons struggling to establish new social contacts after the loss and maintain their previous social contacts and they addressed this difficulty in the counselling sessions. More specifically related to the grieving process, some counsellors indicated that their clients missed helpful encounters with other bereaved persons, e.g. in peer-support groups. Due to reduced social contacts, a lack of practical social support was also mentioned. Furthermore, bereaved clients specifically addressed their unmet need for comforting physical contact.

3.2.2. Loss of routines

Another strain caused by the pandemic was the loss of routines. Bereaved persons, like others, could not engage in activities, as recurring meetings of clubs, societies or sports groups decreased in their frequency or were cancelled due to legal measures. As the counsellors stated, their clients considered routines especially important to structure the day and to provide stability during bereavement. Routines could also provide a positive distraction from focusing too intensely on the loss and its painful consequences. Thus, for some clients, the reduced routine activities led to psychological distress and a heightened confrontation with their grief.

3.2.3. Additional stressors

According to the counsellors, clients also addressed additional stressors that were a consequence of the COVID-19 pandemic. Clients addressed the problem of making plans in the face of a dynamically changing pandemic situation. Especially for families, the pandemic was an extraordinary challenge. Themes in counselling were for example organising the day care or home-schooling of children while working in the home office. Thus, clients lacked time for recreation. Additionally, counsellors reported that their clients worried about the health of their family members, such as elderly persons or persons at special risk for COVID-19. More specifically related to the grieving process, these additional stressors also limited the possibility for families to share their grief and be responsive to the needs of family members.

3.2.4. Societal impact of the pandemic

During counselling, clients also addressed their feelings concerning the societal impact of the pandemic. One important aspect concerned the media coverage of COVID-19. As in the general population, some clients felt that the media was overdramatising the situation; consequently, they criticised the official restrictions. More specifically related to bereavement, the daily reports of the death statistics became a theme in counselling. Some clients experienced this as a permanent confrontation with their loss and were distressed. For them, these statistics also conveyed a sense of deindividuation and did not do justice to the many individual fates behind the respective numbers.

3.2.5. Personal values and priorities

According to the counsellors, some clients expressed that the pandemic had led them to reflect on their own values and priorities in life. This reflection could be self-critical, e.g. when clients wondered whether their previous goals in life had been egoistic or superficial. They reconsidered personal values and questioned previously held assumptions critically. Other statements, however, suggest an increased appreciation of life and a commitment to value-oriented action. Thus, the pandemic may also have been an occasion for personal growth.

3.2.6. Impact on bereavement support / health care institutions

According to the counsellors, the pandemic-related restrictions on bereavement support or health care institutions also emerged as an important theme in counselling. Face-to-face counselling sessions were reduced or cancelled; holding group meetings remained difficult for a long period. Additionally, other health care services became limited. Some hospitals, for example, stopped the admission of patients or closed down wards. Some statements indicate that grief counselling had to compensate for other helpful resources (e.g. social contacts, peer-support) that were no longer available.

4. Discussion

The results of the present study show that, according to the participating counsellors, COVID-19 has affected the topics in grief counselling. Grief researchers have hypothesised that the pandemic could aggravate certain risk factors for PGD. Our results show that these pandemic-associated risk factors have become more important topics in grief counselling. In the quantitative analysis, more than 90 percent of the participating counsellors reported that their clients addressed the lack of social support, limited possibilities to accompany a dying person and the absence of traditional grief rituals. At least two thirds of the participants stated that the risk factors loss of routines, traumatic circumstances of the death and additional stressors became more important topics in counselling sessions. The risk factors shattered assumptions and confrontation with one’s own mortality were endorsed less frequently. Our qualitative analysis corroborated these results and expanded them by providing a more detailed description of the previously established pandemic-associated risk factors. The remaining statements allowed the identification of three additional themes: the societal impact of the pandemic, personal values and priorities and the impact of the pandemic on bereavement support and health care.

4.1. Pandemic-associated risk factors for PGD as topics in grief counselling

Reduced social contacts affected nearly all people in the pandemic and increased social distancing was associated with negative mental health outcomes (Marroquín et al., 2020). However, these effects could be even more pronounced for bereaved persons, since they may experience a greater need for social support and contact (deCinque et al., 2006; Harrop et al., 2021). According to our qualitative data, counsellors felt that especially the pandemic-related difficulties in meeting other bereaved persons, e.g. in support groups, and in building a social net became more important in their sessions. These social needs and tasks may be very specific for mourners (Stroebe & Schut, 1999, 2021): losing a loved one also means a disruption of one’s social net. Therefore, bereaved persons have to build new relationships or redefine their social role. Concerning the effect of official restrictions on accompanying a dying person and on funerals, our results confirm that the absence of traditional grief rituals has become an important topic in grief counselling. This finding aligns with the results of a recent study showing that distress related to the circumstances of the death and the memorial service affected a large number of bereaved people during the pandemic (Neimeyer & Lee, 2022). It is unclear how this will influence bereavement outcomes: A recent review found an inconsistent association between funeral practices and bereavement outcomes (Burrell & Selman, 2022). The authors suggest that funeral restrictions per se may not necessarily have detrimental effects, as long as the bereaved can shape the rituals in a way that is meaningful to them. Since the funeral restrictions became a very important topic in the counselling sessions, this could mean that the clients were distressed by them and had not had a chance to shape the grief rituals in a meaningful way. This hypothesis warrants further research.

4.2. Additional themes

The theme societal impact of the pandemic reflects that clients addressed their feelings about governmental measures to curb the pandemic during the sessions. Importantly, this theme also reflects that clients addressed the media coverage of the pandemic. For some clients, the constant media coverage meant a continuing reminder of the death. For others, the death statistics meant a de-individuation of the deceased and led to the feeling that individual losses were not adequately acknowledged (Torrens-Burton et al., 2022). This facet of the theme aligns with the concept of disenfranchised grief (Doka, 1999). While grief researchers have speculated that disenfranchised grief may be a consequence of COVID-19 among the bereaved (Albuquerque et al., 2021; Stroebe & Schut, 2021), our results suggest that it has become an important topic in grief counselling. Considering the impact of the pandemic on bereavement support and health care, our findings align with previous research (Harrop et al., 2021) highlighting that bereaved persons report a high level of support needs in combination with severe difficulties accessing support. Importantly, our results show that this perception became also a topic in grief counselling, i.e. among persons who had accessed existing support but still felt that their needs were not being met adequately. The last newly identified theme concerned personal values and priorities. Re-examining previously held beliefs and values occurs frequently after bereavement. It has been suggested that it can even contribute to positive outcomes such as posttraumatic growth (Calhoun et al., 2010; Michael & Cooper, 2013). When interpreting this finding, it is important to bear in mind that this reconsideration of values may possibly reflect a more general pattern: Previous research suggests that the pandemic has led to an increased reconsideration of personal values in the general population (Venuleo et al., 2020). Thus, all additional themes should not be interpreted as risk factors for PGD but constitute topics that have become important in grief counselling during the pandemic.

4.3. Grief and bereavement care in COVID-19

The COVID-19 pandemic was and is an extraordinary period of time for the general population and not only bereaved persons. Our results suggest that certain changes in topics of grief counselling may mirror broader societal challenges, such as the heightened importance of reconsidering personal values. Importantly, our results also corroborate that the pandemic presented bereaved clients with very bereavement-specific stressors, such as official restrictions on accompanying a dying person or on funerals. Recurring to the research on PGD, our quantitative results can be interpreted as a tentative confirmation of the proposals from various researchers (Amy and Doka 2021; Diolaiuti et al. 2021; Djelantik et al. 2021; Eisma et al. 2020, 2021; Hamid and Jahangir 2020; Helton et al. 2020; Mayland et al. 2020; Menzies et al. 2020): certain risk factors for PGD increased during COVID-19. At the same time, it remains unclear whether this will also lead to a rising prevalence of PGD in the next years: First, risk factors do not necessarily culminate in diagnoses. Second, all literature-identified risk factors have been proposed before the pandemic. Third, there was an apparent variability in the importance of the different risk factors for grief counselling. Unexpectedly, the pandemic may also have been a chance for personal growth in the sense of critically re-examining one’s personal values and priorities. In a similar vein, Torrens-Burton and colleagues (2022) mention for instance that for some bereaved persons apparently distressing factors like isolation may even have been beneficial. For them, isolation also meant avoiding social situations that would otherwise have been difficult for them to manage in their grief.

The results of our study align with previous qualitative studies that investigated grief experiences and challenges during the pandemic (Helton et al., 2020; Mortazavi et al., 2021; Pearce et al., 2021; Torrens-Burton et al., 2022). However, they add a quantitative perspective on the relevance and differences of various topics that were addressed in grief counselling. These variations in the clients’ current needs may necessitate a flexible approach in grief counselling (Simonsen & Cooper, 2015). However, counsellors may also need specific pandemic-related knowledge and competencies to capture the impact of, for example, restricted access to a dying beloved person (Harrop et al., 2020). As part of a larger evidence base, our findings can also inform a public health perspective on bereavement and grief in a pandemic. Our results highlight that the absence of traditional grief rituals became an important topic in grief counselling. Previous studies have suggested that bereaved persons can find alternative, meaningful funeral rituals in the pandemic (Burrell & Selman, 2022; Neimeyer & Lee, 2022). If empirical evidence shows a mitigating effect of such alternative rituals on grief-related distress, one recommendation for future crises could be to increase knowledge about and access to such alternative rituals. As another example, lack of social but also professional support became an important topic in our study. From a public health perspective, one recommendation could be to establish a proactive tiered approach to bereavement care, e.g. through helplines (Bates et al., 2022). This may include offering various preventive services like educational online materials or phone consultations as well as interventions like virtual sessions with a mental health professional, if needed (Taylor, 2022).

4.4. Future directions

To the best of our knowledge, the study is one of the first to analyse topics in grief counselling that became more important during the pandemic with a clear focus on pandemic-associated risk factors for PGD. Future qualitative and quantitative studies should complement our findings with the perspective of the bereaved clients. Previous research has used qualitative methods to examine grief experiences during the pandemic in non-treatment seeking bereaved samples (Mortazavi et al., 2021; Torrens-Burton et al., 2022). However, given the fact that not all bereaved suffering from burdens seek help in professional care (Harrop et al., 2021), it is reasonable to distinguish between mourners who seek and who do not seek help in future research. Furthermore, longitudinal studies are needed to assess the impact of the pandemic-associated risk factors on the actual prevalence of PGD. Future studies should also investigate how the pandemic affected health care professionals who provide bereavement support (Pearce et al., 2021; Stroebe & Schut, 2021).

4.5. Strengths and limitations

Several limitations must be born in mind when interpreting the results of the study. First, data were collected from the counsellors and not directly from the bereaved clients. This may have caused some bias in information. Second, we used a convenience sample of German grief counsellors. Thus, the generalizability of our results remains to be tested. Third, the sample size was relatively small, especially in the qualitative analysis. Fourth, data was collected from May 2021 to February 2022: the impact of the pandemic may have varied during the period of the data collection and thus, different issues may have been especially relevant at differing time points. At the same time, the present study has several important strengths. First, it is a timely examination of pandemic-associated risk factors for PGD as addressed in grief counselling. It thus offers an important insight how the topics of grief counselling changed through the pandemic and which potential risk factors of PGD became more important topics in counselling. Second, it combines quantitative and qualitative methods to provide a more detailed description of the research topic and thus yields a better understanding and more complete evidence that either method alone. Third, it uses information from a sample of experts: The grief counsellors in the present sample provided bereavement support before and during the pandemic. They were thus ideally qualified to report on respective changes in their work. Additionally, grief counsellors usually support many clients simultaneously and could therefore summarise and provide information about more general topics across different clients.

5. Conclusion

According to counsellors, the pandemic has changed the topics that clients address in grief counselling. Risk factors for PGD became important topics in counselling sessions, especially the lack of social support and disturbed grief rituals. Still, it remains unclear how large the impact of these risk factors on the future prevalence of PGD will be. Grief counselling is a low-threshold intervention that is usually accessed early after bereavement and acts as a preventive service. Pandemic-induced difficulties in adaptation to bereavement may therefore be observable in counselling before they are noticeable in therapy. Researchers and clinicians should, therefore, carefully monitor grief processes and risk factors to provide the best possible care for bereaved people in a timely manner when it is needed.

Acknowledgements

The authors would like to thank Lana Reb for her support regarding the recruitment of grief counsellors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are available on reasonable request.

Additional information

Funding

This work was supported by the Bavarian State Ministry of Family Affairs, Labour and Social Affairs. The open access publication of this article was supported by the Open Access Fund of the Catholic University Eichstaett-Ingolstadt.