Bereavement in Times of COVID-19: A Review and Theoretical Framework

Abstract

A review of the literature on adaptation to bereavement during the COVID-19 pandemic was conducted to assess the current state of knowledge. Scopus, Web of Science and Google Scholar databases were searched for studies published during the first 6 months of the COVID-19 outbreak. 44 articles were included in the review. Narrative synthesis showed that knowledge was largely based on expert assessments of prior bereavement research and professional experience; there is so far absence of empirical evidence linking features of COVID-19 bereavement situations to health outcomes. Severe negative consequences have been consistently predicted by authors. There is still relatively little consideration of positive or compensatory processes or the possibility that these could alleviate the effect of the shocking, traumatic circumstances. With two notable exceptions, there has been lack of attention to the role of theoretical models for guiding research and practice. A theoretical perspective (the Dual Process Model, DPM) was applied to the information derived from the available articles. Two features of the DPM framework illustrated its relevance: 1. It enables systematic assessment of the range of loss- and restoration-related challenges for the bereaved; 2. It speaks for extension of psychotherapeutic intervention to manage secondary, restoration- as well as primary, loss-oriented stressors; studies have demonstrated that this may increase the effectiveness of intervention. Directions for future research and DPM application are suggested.

Background

The devastating impact of the COVID-19 pandemic has been documented for countries all across the world, with high death tolls recorded and indications that survivors, relatives and friends are deeply affected. There has also been an increase in death rates from other causes during the pandemic, sometimes attributed to postponement of treatment of other life-threatening diseases or to avoidance of health care facilities to avoid infection. Accordingly, the number of bereaved people has risen. Verdery et al. (2020) made an assessment of the numbers of people likely to be affected in the U.S., calculating the average number experiencing the death of a close relative for each COVID-19 death. If 190,000 Americans die from COVID-19 (as some models projected by August, 2020, with reasonable accuracy, Verdery, personal communication), then approximately 1.7 million become bereaved.¹ The social impact is clearly huge.

The unprecedented measures taken to protect the health of communities, lower the risk of infection, and promote safer care during this pandemic incorporate changes not only in the circumstances and context of deaths but also in routines of ongoing, daily life, ones which naturally also affect bereaved people. Frequently mentioned COVID-19-related actions include decrees by governments or policy makers about care during the terminal illness, funeral/burial arrangements, associated with physical distancing/social isolation rulings with limitations to social contacts, as well as hygiene requirements.

The changed circumstances and defining features relating to COVID-19 deaths include the circumstances of final illness: isolation of the terminally ill person frequently without the presence of loved ones, depersonalization of protective clothing and communication through masks or visors and the wearing of gowns, with observation often from a distance, rapid occurrence of death (frequently sudden and/or unexpected), and removal of the corpse, also in isolation, and remote identification of the body. Funerals/burials are likely to be sharply curtailed, postponed or held remotely (and with very few persons present). There is sometimes little chance to say farewell in accustomed ways, or to observe cultural or religious mourning practices; there may be regrets or anger about possible preventability of the death. A persisting difficulty has been noted: social isolation has brought with it the lack of physical support from family and friends or physically-present spiritual support, reflecting sometimes severe societal disruptions in general. Such distancing can intensify feelings of loneliness that is part of any bereavement experience, even without isolation orders in place. Added to these are a variety of changes in living conditions (e.g., during lockdowns, if there is need for quarantine, due to economic hardship). Not least, for some, the measures impose a sense of lack of autonomy, a feeling of freedom lost and gone, which is hard to bear. In some countries including the U.S., the feeling of social injustice prevails as well (e.g. due to lack of equality of care across socio-economic status groups).

There are reasons to assume that the features described above affect grief and grieving for those who have lost a close person through a COVID-19 viral infection (or from other causes during the pandemic), making the experience different in critical respects from other types of bereavement. To our knowledge, this body of literature has not yet been reviewed. Thus, the primary aim of this article was to provide an overview of the knowledge which is so far available about the experience of bereavement in times of COVID-19 and to suggest directions for further research.

A relevant question is whether theoretical models have been applied and/or can contribute to understanding the experiences and consequences of bereavement associated with this pandemic. The scientific study of bereavement should have application, given that theoretical models are designed to identify regularities in grief and grieving under any circumstances, often including principles to guide counselling or therapy. Thus, the second aim was to explore the implementation of theoretical approaches to the situation of COVID-19 bereavement, and to illustrate the potential relevance of one model, the Dual Process Model of Coping with Bereavement (DPM, Stroebe & Schut, 1999). Uniquely for bereavement models, Fiore (2019) conducted a systematic review of (quantitative) studies to establish the extent and quality of evidence regarding the DPM. She concluded that it accurately represents the bereavement experience, while pointing out certain limitations (e.g., shortage of studies applying the DPM to guide psychotherapeutic intervention); further testing is called for.

Outline of the DPM Model

The DPM (for description of main parameters: Stroebe & Schut, 1999, 2001, 2010; see Figure 1 below) was designed to represent the bereavement experience in ways that built on but extended earlier models. Its basic parameters include descriptions of types of stressors associated with bereavement (to categorize what is troublesome), understood to be either loss-oriented (LO) or restoration-oriented (RO). Loss orientation refers to the concentration on, dealing with, processing of stressful aspects of the loss experience itself, most particularly, with respect to the deceased person (e.g., visiting the grave to be close to the deceased; looking at photos of him/her). Restoration orientation refers to secondary (to the loss itself) sources of/coping with stress. RO focuses on what else needs to be dealt with as a result of the loss, and how these matters are dealt with (e.g., taking up employment to compensate for the deceased’s lost income; learning skills that had been done by the deceased).

Figure 1.

The Dual Process Model of Coping with Bereavement Stroebe & Schut 1999).

In addition, coping processes (ways of dealing with the stressors) were postulated, entailing dynamic oscillation. This is a process mandated by the fact that there are both LO and RO types of stressors to deal with, which cannot be done simultaneously. Since each type has to be coped with for adjustment to be made to the loss, to reduce the stress and negative consequences, shifting back and forth between dealing with the one or the other type of stressor has to be part of the coping process: oscillation must take place, coping involves both confrontation and avoidance of LO and RO stressors, as well as positive versus negative appraisal processes (indicating how meaning making may take place). At times, there will be respite from dealing with loss and change, the bereaved person must do other things. Coping takes place within the context of everyday living. It also takes place in family context, family-level stressors and coping have been examined (Stroebe, 2010; Stroebe & Schut, 1999).

The DPM covers description of outcomes, the consequences of coping (e.g., adjustment to the loss, mental and physical health effects, persistence or decline in levels of grief over the course of time). Furthermore, the concept of overload was more recently introduced into the model (Stroebe & Schut, 2016), defined as the bereaved person’s perception of having more than s/he feels able to deal with – too much or too many activities, events, experiences and other stimuli”. Sometimes coping cannot proceed through healthy oscillation between dealing with LO and RO stressors, the burden of either, or both (or indeed, of additional non-bereavement-related daily stressors) may simply be too great for this to occur.

In this article, review of the available studies of the circumstances and consequences of bereavement in COVID-19 times is followed by application of the DPM. The current state of knowledge is assessed and suggestions made for research and practice.

Methods

Type of Review

A review of the literature was conducted with narrative synthesis of articles in scientific sources. The available evidence was not (yet) suited to a systematic or metanalytic review of empirical investigations. There is understandably still a lack of well-designed studies addressing the impact of the COVID-19 pandemic on adjustment among those who become bereaved. Nevertheless, in our view, the various research contributions increase understanding of the nature of the experience and expected outcomes, meriting review. They can be drawn on for designing further studies.

Search Strategy and Study Selection

The search was conducted in a time-limited manner, given the need for swift completion to assess the current state of knowledge and to try to give guidance for further research. It was conducted during the week of June 3rd, 2020. Scopus, Web of Science and Google Scholar were searched, using the terms “COVID-19” and “Bereavement”. Existing files were examined up to that time too (e.g., from the NCBI system). Narrative synthesis showed more consistency than inconsistency about bereavement challenges and manifestations across the selected articles (see below). Unique elements and distinct vantage points were also provided in the articles. Our assessment was that – with one exception (see Discussion section) - subsequently-published articles, which were monitored until submission of this review, had not yet added significantly to this knowledge base.

Inclusion and Exclusion Criteria

Only English language articles were included. Given the type of available studies outlined above, inclusion criteria were broad; articles were not excluded on the basis of specific design features and/or evaluation of quality. The scope of the articles selected from these sources covered bereavement/loss reactions of people, communities or cultures affected by COVID-19. The impact of deaths on care professionals was included, to the extent that the article in question was concerned with their loss/grief reactions. Articles focusing primarily on policy making or health care, or on the role and response of palliative care and other involved organizations, were excluded.

Selection of Articles and Their Characteristics

44 articles were identified as eligible for inclusion. These studies are summarized in Supplementary File 1. Just over half (approximately 55%) of the articles describe experts’ understandings of grief, mourning (customs) and bereavement during the pandemic in the form of short commentaries (editorials, letters to editors, opinion pieces, brief notes). These typically highlight critical concerns (e.g., a potential rise in complicated grief reactions). Nearly all of the others review studies of pre-occurring pandemics and bereavement experiences (approximately 45%); a few of these are systematic ones (e.g., Burrell & Selman, 2020; Guessoum et al., 2020; Harrop et al., 2020). Some of the articles are quick surveys, aimed at assessing what can be learned at this relatively early stage in the pandemic. Authors have drawn on such sources for predicting reactions to the COVID-19 pandemic (e.g., natural disasters; deaths in ICUs, pan- or epidemics), for example, to derive advice on systems level responses to mass bereavements (Harrop et al., 2020). As detailed below, hardly any articles include empirical data, only a few give specific intervention guidance, and theoretically-based approaches are rare.

As many as 13 countries are represented among the included articles. While most are from the U.S. (approximately 40%) and U.K (approximately 18%), their origins spread widely across the world. Reflecting this diversity, culturally-sensitive aspects are sometimes addressed by authors. Unique, bereavement-related ramifications among people in cultures with different belief systems and/or customs are described (e.g., in China, India, Ireland, Iran or Portugal).

Results

The health impact of COVID-19 during bereavement. The potential mental health impact on people in general (not just the bereaved) has been widely discussed. Extreme or differently-directed emotional reactions have been described (toward authorities; health care professionals, etc.), including anger, shame, fear, depression, loneliness (Ahmadi & Ramezani, 2020). Increases in mental difficulties/disorders associated with bereavement have also been predicted and many anticipate increases in Prolonged Grief Disorder (PGD; e.g., Boelen et al., 2020; Eisma et al., 2020; Gesi et al. 2020; Goveas & Shear, 2020; Johns et al., 2020; Kokou-Kpolou et al., 2020; Masiero et al., 2020; Mortazavi et al., 2020; Wallace et al., 2020; Zhai & Du, 2020). The COVID-19 situation incorporates various features that have been associated with mental health complications (PTSD, anxiety disorders, complicated grief), or ones that have been described as risk factors (e.g., sudden and/or traumatic death) in the past (see Eisma et al., 2020; Solomon & Hensley, 2020). Goveas and Shear (2020) list PGD risk factors related to death during COVID-19, covering the circumstances, context and consequences of the death. Johns et al. (2020) describe factors that include (but are not limited to): experiencing more than one death in a short time; strong dependency on the one who died; shocking, premature, unexpected death circumstances; death perceived as preventable; witnessing the death and/or suffering; previous mental illness, especially PTSD. Masiero et al. (2020) discuss various, commonly-experienced sources of COVID-19 traumatic experience across different countries and likely increases in PTSD, complicated grief and mental health disorders in general. Rao et al. (2020) point to the disproportionate impact on vulnerable subgroups in a resource-poor country such as India.

Some authors have described aspects of idiosyncratic and/or unprecedented reactions relating to bereavement (e.g., Carr et al., 2020; Gesi et al., 2020; Kelly, 2020; Kokou-Kpolou et al., 2020; K. J. Moore et al., 2020; Morris et al. 2020; Singer et al., 2020; Sun et al., 2020; Usher et al., 2020; Wallace et al., 2020; Zhai & Du, 2020). For example, Carr et al. (2020) describe features of the COVID-19 experience which potentially compound bereavement difficulties in adjustment. Singer et al. (2020) and Wallace et al. (2020) also cover pre-death, anticipatory reactions. Kelly (2020) and Walsh (2020) discuss implications for families and Sun et al. (2020) mental health care issues and how to deal with them. Others have examined the impact on specific subgroups, particularly older persons (e.g., Carr et al., 2020; Goveas & Shear, 2020; Ishikawa, 2020; K. J. Moore et al., 2020), but also adolescents (Guessoum et al., 2020) and the Black community in the U.S. (S. E. Moore et al., 2020). A few have focused specifically on the potential rise in grief complications due to the unique nature of COVID-19 bereavements (e.g., Eisma et al., 2020; Johns et al., 2020; Mortazavi et al. 2020). Examining different outcomes, Raker et al. (2020) used data from Hurricane Katrina to predict indirect mental and physical health consequences of the COVID-19 pandemic.

Emergent difficulties specifically in relationship to the attempts to reduce infection rates have been predicted (e.g., various government enforcements; changed funeral/burial policies, etc.), again based on past documentations. For example, Mortazavi et al. (2020) described the impact of social distancing and isolation in Iran, relating this particular phenomenon to a potentially-increased prevalence of complicated grief. Quite a few writers have focused on CIVID-19 changes in burial/funeral practices, often describing the governmental policies that determine these, and suggesting how they may affect the grieving process and adaptation (e.g., Aguiar et al., 2020; Burrell & Selman, 2020; Johns et al., 2020; Mayland et al., 2020; O’Mahony, 2020). On the one hand, there are reality-confronting possibilities (of corona as well as mortality), on the other hand, the situation may lead to avoidance. In the face of such difficulties, one might speculate that letting go, finding a place for the deceased in ongoing life, relinquishing the old ties/bonds and moving on may not be tasks that can yet be dealt with.

Resilience, positive consequences. While negative consequences have understandably been the focus of most authors describing the impact on bereavement of death during COVID-19 pandemic, some have also emphasized positive developments and the resilience of most people “even in the midst of dire circumstances” (Pfefferbaum & North, 2020). Walsh(2020) highlighted positive aspects following her resilience-oriented systems perspective, systematically addressing how families deal with the multiple, complex, pandemic-related losses. Furthermore, it has been argued that alternative ways of commemorating the deceased person may compensate for the minimalization of services or lack of attendance at the funeral (see Burrell & Selman, 2020). Abel and Taubert (2020) pointed out the gains to be had for those affected, due to the emergence of compassionate communities, and the availability of technological opportunities, for example, to compensate for social distancing.

Mental health care, support and psychotherapeutic intervention for COVID-19 bereaved people. Mental health care needs in general of those experiencing COVID-19 loss and grief have been documented, with suggestions for providing care and recommendations for dealing with COVID-19-specific difficulties (e.g., LeRoy et al., 2020; Sun et al., 2020). Attention has been paid to diverse associated complexities, including those arising from mental disorders (e.g., Gesi et al., 2020) and for high risk subgroups such as older persons (e.g., Goveas & Shear, 2020; K. J. Moore et al., 2020). Others have described specific provisions for care, including the use of palliative care tools and psychological strategies (e.g., Morris et al., 2020), and extending concern to predeath needs of those who become bereaved (e.g., Singer et al., 2020). Responses to mass bereavement at the system level have been reviewed, to inform service provision and policy making during the COVID-19 pandemic (Harrop et al., 2020), while Maddrell (2020) gives an unusual geographic analysis to locate existing inequalities and failures of governance across geographic areas, to further wellbeing and work toward changing policy interventions.

Investigation has extended to descriptions of support and intervention programs for grief (complications). Boelen et al. (2020) describe a remote cognitive behavior therapy (CBT) intervention delivery; Harrop et al. (2020), in the study cited above, also describe support initiatives that may help; Kokou-Kpolou et al. (2020) identify traumatic grief features and how to deal with them. Solomon and Hensley apply Eye Movement Desensitization and Reprocessing (EMDR) to the pandemic situation. In an unusual approach, Rushton et al. (2020) suggest the relevance of dramatic interventions (applying the way that ancient Greek tragedy helped processing of moral suffering). In their analysis focusing on older persons, Carr et al. (2020) present some novel, appropriately-tailored interventions. As a final example, Wang et al. (2020) describe how to support patients and family through grief and bereavement, providing a tabulation of needs at different times through the loss process to help understanding of duration-of-bereavement-related changes.

The professional caring, grieving context surrounding the bereaved. Concern has been shown about the severe impact of the pandemic on health care professionals (front-line workers, hospital clinicians, counsellors, psychotherapists, psychiatrists, counselling psychologists, service providers in general), given their roles in supporting not only patients dying from COVID-19 but also the patients’ grieving families. Thus, though our focus is on the bereaved, reactions of caring professionals need consideration and we give references for further information.

Some writers have provided strategies for professionals caring for families; Walsh (2020) for example, offers practice guidelines to facilitate adaptation and resilience. Others focus on concerns about the care providers themselves when faced with COVID-19-related situations. Mayland et al. (2020) draw on knowledge from previous pandemics on how to support the bereaved; Wallace et al. (2020) describe considerations specifically for palliative care providers, while Kelly (2020) does so for psychiatrists; Vieta et al. (2020) considers the role of psychiatry more broadly in times of COVID-19. Lichtenthal et al. (2020) give recommendations for physicians dealing with COVID-19 bereaved. Selman et al. (2020) provide advice for hospital clinicians and their staff. Williamson et al. (2020) describe ways for dealing with moral injury among front-line workers, defined as “the feeling of profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code” (p. 317, Litz et al., 2009). Masiero et al. (2020) link such experience to “decision fatigue”.

Empirical, applied and theoretical scope of articles. Empirical investigation of COVID-19 bereavement is still in its infancy. Up to the time of the literature search, one qualitative analysis of reactions following the outbreak had appeared (Ahmadi & Ramezani, 2020), and another had given a qualitative analysis of the impact of COVID-19 on the Black community including case material (S. E. Moore et al., 2020). Two further empirical studies focused on very different aspects: one presented a scale of COVID-19 anxiety (Lee, 2020) and another an index for assessment of the number of deaths and bereaved persons (Verdery et al., 2020).

The reviewed articles, reflecting a variety of bereavement expertises, are generally of an applied nature, seeking to describe COVID-19-related bereavement phenomena, providing descriptions of these at individual, interpersonal and societal levels. Authors have striven to derive practical implications on the basis of established, pre-COVID-19 knowledge, given the lack of empirical results from the pandemic so far. Only two of the reviewed articles were explicitly theory-driven. Walsh (2020) applied a family resilience framework to pandemic-related losses, adopting a systemic approach. This perspective enabled structured analysis of COVID-19 bereavement experience in terms of losses and challenges, through systematic scientifically-based analysis of positive and negative family processes. Solomon and Hensley (2020) described EMDR complicated grief treatment guided by the Adaptive Information Processing Model and extended coverage to include the attachment theory and DPM frameworks for COVID-19 bereavement application. Two articles make reference to specific grief frameworks to guide and structure their literature reviews: Bertuccio and Runion (2020) systematically examined well-established grief manifestations; Rao et al. (2020) explored psycho-social-spiritual aspects of palliative care. There is further occasional mention of theoretical approaches. Mortazari et al. (2020) based discussion of experiences of loss and grief on Kübler-Ross’s stage model (Kübler-Ross & Kessler, 2005). Nair and Banerjee (2020) made mention of application of models, again including the stage model (Kübler-Ross & Kessler, 2005), and the DPM (Stroebe & Schut, 2010) among others. The other articles make hardly any mention at all of theoretical perspectives.

All in all, this amounts to little application of theoretical perspectives, yet Walsh’s approach demonstrates the usefulness of a framework for defining features of the COVID-19 bereavement experience and developing practice guidelines and Solomon and Hensley’s describes the application of one therapeutic method for professional intervention. There is room for further exploration of the role of theories in this pandemic context.

Application of the Dual Process Model of Coping with Bereavement

Relevance of the DPM Framework to the Reviewed COVID-19 Bereavement Studies

The next step in conducting this review was to find links between the bereavement phenomena and parameters of the DPM theoretical framework. Information from the extracted articles is listed in the right hand column of Supplementary File 1.

LO and RO stressors and consequences. The reviewed articles cover a number of COVID-19-related LO as well as RO stressors and list diverse reactions/consequences, summarized in Table 1. The “plethora of losses” characteristic of COVID-19 bereavement experience (see Solomon & Hensley, 2020) and the variety and extent of DPM-postulated LO and RO stressors in relationship to COVID-19 bereavement, are clearly evident. In fact, it proved relatively easy to distinguish these two types in the articles reviewed. It was also not difficult to see links made by authors between stressors and outcomes (grief; distress; health consequences, etc.), who often base their statements on patterns derived from previous bereavement research; direct empirical evidence is still lacking.

Table 1.

LO and RO Stressors and Associated Reactions/Consequences (Compiled From Reviewed Articles).

LO stressors	LO-related reactions	RO stressors	RO-related reactions
– Lack of emotional & practical preparation time – Circumstances of terminal illness, dying process (e.g., isolation, desolate dying situation; patient’s physical discomfort, difficulty breathing; illness-related uncertainty) – The traumatic burden for (bereaved) relatives of treatment of their dying relative in isolated ICU conditions – Difficulty/impossibility to say goodbye due to enforced isolation; realization of death more difficult without viewing the body or saying goodbye, associated with denial and avoidance of the loss); but – Morally distressing circumstances: perceptions of violation to one’s own moral or ethical code (relating to suboptimal care of the dying person, due to resource scarcity (including difficulties relating to ethical decisions in limited resources) – Circumstances of death unexpected and/or traumatic (associated with continued confrontation, rumination and complicated grieving, but note avoidance too). – Experience of “staggering”, multiple losses/deaths of close persons and their ongoing nature; threat to oneself (particularly. among vulnerable older, sick) – Frequent reminders of death (rates), media coverage, exposure to distressing images; hearsay, potentially impacting negatively on adaptation but: – Pandemic circumstances may be dealt with by suppression of emotions (in certain cultures particularly), linked to avoidance and denial rather than confrontation – Profound changes in funeral practices, severe restrictions (inc. social & relational ones): enforced direct cremations; banned ceremonial attendances – Lack of opportunity for physically-given/received support – Lack of social/cultural recognition of the loss, related to impaired support resources; absence of the soothing rituals with opportunity to express grief/comfort	– Guilt/shame/regrets (e.g., if one infected the deceased, feeling Responsible for the death; at one’s powerlessness, perceived neglect of the dying or deceased person) – Anger toward system/officials about the death: “undignified” body disposal; regarding the patient’s own mistakes; – Moral responsibility: guilt, anger, anguish, distress exacerbated by feelings of moral responsibility – Loneliness; excessive bitterness and a sense of perceived purposelessness in life. – Anticipatory grief phenomena, which are also threatening, given uncertainty of illness outcome – Disenfranchised grief: 1. Too many COVID-19 deaths for individual recognition, the deceased considered a statistic, causing complications in grieving 2. Linked to failure by deceased to follow mandated rules, impacting on social interactions in bereavement	– Economic difficulties, high financial costs (particularly in U.S.) – Loss of work, unemployment, livelihood/financial insecurity, furloughs, salary reductions, homelessness – Lockdown-related difficulties with one’s work, harder to get new employment if needed post-loss – Medical support concerns (e.g., lack of insurance; health care access; failed medical intervention due to lack of resources, facilities, means to pay) – Care, management and treatment for existing mental and physical illnesses (associated with accentuation of health care disparities) – High-risk frontline, repeated exposure stress; own COVID-19 illness, intensive care admission – Quarantine/confinement/social isolation (restrictions in social, recreational, and occupational activities, including travel e.g., for attending memorial ceremonies) – Family (particularly children) and community level difficulties/disruptions in living arrangements (e.g., schooling irregularities: home schooling; access to shops) – Painful physical separation from family and close friends. – Family tensions and quarrels (violence) associated with staying at home, no family/friends visits – Disruption of connectedness, autonomy and freedom through suspension of gatherings, travel, closing of religious centers, lockdowns, social distancing – Erosion of coping resources (social support), relating to social isolation, (lack of positive appraisal: sense of community, uplift). – Needed support for vulnerable bereaved people may be lacking due to distancing and withdrawal – (Perceived) rejection (e.g., stigmatization from others due having a COVID-19 death in the family) – Impact of negative campaigns, victimization, rise in racism – Disruptions to social norms, face-to-face rituals, mourning practices impacting on ongoing life beyond grief, grieving – Worries, fears about getting the viral infection, fear of contamination/contaminating others – Difficulties dealing with new technology needed due to distancing (online medical forms, phone appointments, etc.) – Uncertainty about the future (under pandemic circumstances) – Lack of/disruption of routines, dislocation, loss of pre-crisis ways of life, threatened loss of hopes and dreams for the future, shattered assumptions about normal life and connections with the world	– A rise in level of general anxiety, worries – Feelings of lack of safety, insecurity – Experiencing prejudice against oneself – Feeling upset related to an intolerance of uncertainty – Loss of feelings of control or purpose – Feeling trapped through isolation – Feeling vulnerability to the spread of rumors, misinformation – Fears for one’s own mortality – Experiencing the allocation of blame toward oneself, a victim of discrimination or of hate crimes

Additional DPM parameters. Other parameters are less evident or at least, less explicitly represented. However, some indications of these parameters are discernible. Positive versus negative appraisal processes, addressed in a few of the articles, relate to the concept of oscillation. For example, authors have described balancing the negative impact of shut-down policies with positive initiatives, such as creating community groups (e.g., supporting vulnerable people; take-away grocery services) to combat social isolation and physical distancing, using modern technology to do so. Positive appraisals have been described as offsetting negative ones (thus also relating to oscillation). These include diverse sources of consolation, about the death (e.g., compassionate care by hospital teams; receiving accurate information about the course of illness, dying), or more generally, noting personal appreciation (e.g., a heightened awareness of nature, relief at the reduction in air pollution, recognition of increases in civilities and mutual aid). Negative effects have been viewed alongside positive ones (e.g., increased online connectivity for work/social interactions, morale boosts though political satire, communal activities). More broadly, mobilization of community/international efforts in many domains have been recorded. The lack of receipt of personal, positive appraisals (community support, feeling uplifted through rituals), ones missing as a result of community shutdowns, was listed among hardships faced during the pandemic.

Evidence is not so strong for other, key, DPM postulates. Oscillation is less tangible, less easily operationalized or measured than LO or RO stressors (Fiore, 2019) and its presence can only indirectly be inferred from the articles. However, Solomon and Hensley (2020) explicitly incorporate the concept of oscillation into their description of EMDR treatment of grief during COVID-19 times. RO stressors are understood to trigger past attachment-relationship trauma, compounding the impact of death of the close person.

Mention is also only occasionally made of the accumulation of critical LO and RO stressors associated with COVID-19, of the burden of having too much to deal with, compatible with the notion of overload. Masiero et al.’s concept of “decision fatigue” would also fit with the concept of overload (and could be both LO and RO stressors related). Walsh drew attention to the overwhelming experience of losses at the family level: “Family distress may result from an overwhelming situation involving the death of a loved one or losses incurred in the wider impact of the pandemic (p. 1)”. Rao et al. (2020) provide insights into COVID-19- related bereavement challenges in India, a country where health care systems are “difficult to access, overburdened, and unaffordable to many (p. 116)”. Further specification of the nature of overload is called for.

Somewhat more attention has been paid to family-level difficulties (LO and RO stressors), covered by a number of authors (see Table 1). For example, the occurrence of multiple deaths within the family in a short space of time, due to COVID-19 has been addressed. The diversity of family difficulties becomes evident too: on the one hand, family quarrels have been linked to confinement and isolation within households, while on the other hand, lack of contact with family and friends has led to painful separation reactions.

Discussion

We set out to review the state of knowledge about the experience of loss of a close person under the current pandemic circumstances and to examine the application of the DPM to COVID-19 bereavement situations. Our strategy was to examine the existing literature from scientific sources, in order to identify defining features of the COVID-19 situation and to chart unique or intensified bereavement react ions. The available information reflects the recency of the pandemic: there is an absence of any strong empirical evidence relating specific features of COVID-19 experience to particular bereavement outcomes; relevant findings had to be drawn from expert opinion and/or derived from earlier, related research, with the majority of the articles being in the form of short commentaries. Predictions of negative effects of the pandemic on bereavement reactions have been made by many of the authors in these sources, as detailed above. It must also be remembered that our review is limited in assessment to a specific window of time, covering the first half year of the pandemic. Nevertheless, although the situation is ever-changing all over the world, researchers have succeeded in documenting the nature of bereavement experience in ways that can fuel further investigation. It is to be expected that well-designed (longitudinal, inclusion of appropriate control groups, etc.) empirical studies of the impact of COVID-19 circumstances on bereavement will emerge in the near future, providing finer-grained information on the nature and extremity of effects of the pandemic on bereavement.

Our review showed that assessment could be made of application of the DPM theoretical approach (albeit with some limitations, pointing again to the need for further empirical investigation). The reviewed studies provide evidence that a wide range of LO and RO stressors are experienced, including some rare ones (e.g., moral distress) as well as those that are more familiar but may involve intensified reactions under COVID-19 circumstances (e.g., loneliness). Different coping strategies for dealing with both LO and RO stressors were also identified (e.g., creating an online ceremony to compensate for being unable to attend one in person). While little mention was made of the need for oscillation in dealing with these stressors in the reviewed literature, given that the situation involves co-occurring LO and RO stressors, it follows that bereaved people will need to “balance” their efforts in dealing with them. Furthermore, the wide range of both LO and RO tasks to be dealt with underlines the possibility of overload. The COVID-19 bereavement situation encompasses many factors that have been linked in the past to poor mental and/or physical health outcomes (although attention has also been drawn to people’s resilience). At the same time it is known that complications in grieving are typically limited to a minority, although predictions are for a rise in numbers due to the pandemic.

Given that its parameters could be applied, the DPM framework may be regarded as relevant to understanding the experience of COVID-19 bereaved persons. But does it contribute in a meaningful way? Looking at its main features: Cataloguing the stressors into LO and RO types provides some order to the variety of challenges faced by bereaved people in times of COVID-19. The concept of oscillation brings realization that not all of these can be dealt with at the same time and that coping with them requires regulatory processing. The notion of overload adds warning that the burdens may accumulate to a health-threatening level. The next question arises: If it is useful, what can be done to further the application of this theoretical approach? Two suggestions come to mind:

Inventorization of LO and RO Stressors

The development of a COVID-19 bereavement-specific list of LO and RO stressors (and their perceived impact) could be a useful step toward inventorization and impact assessment of a bereaved person’s difficulties and could help toward tailoring assistance to match his or her (and/or the family’s) particular profile (e.g., to focus on a better LO/RO balance or to find ways to reduce overload). The LO and RO stressors listed in Table 1 provide a useful starting point for developing such a measurement instrument. We noted earlier that a 5-item measure of dysfunctional anxiety already exists: Lee (2020) developed this brief mental health screener to identify probable cases of COVID-19 related anxiety. A DPM-COVID-19-relevant stressor/coping scale could add to knowledge. It could be used as an assessment tool to aid identification of those most at risk of experiencing (a variety of) extreme difficulties during bereavement in COVID-19 times, for example, to profile a bereaved person’s particular challenges.

DPM-Guided Psychotherapeutic Intervention

The DPM leads to different suggestions for counselling or therapy from those suggested in the articles reviewed above. Intervention protocols have frequently followed CBT principles, focusing on coming to terms with the death of the close person. As such, these are loss-oriented. Following all that has been said above, it would follow that restoration-oriented tasks should be addressed too. There is support for this line of reasoning. Some recent studies have adopted the DPM framework and included treatment of RO stressors (for review: Fiore, 2019). Shear et al. (2005) and Chow et al. (2019) demonstrated that including tasks directed toward coping with RO stressors was associated with more improvement than when the intervention focused only on LO; Nam (2017) showed that RO intervention was more effective than psychoeducation. These studies suggest that RO stressor management is important in helping those bereaved who need professional help. In the COVID-19 bereavement situation, having identified the specific, troublesome LO and RO stressors experienced by the client, intervention could be designed to manage these systematically. Protocols already developed by Shear et al. (2005), Chow et al. (2019) and Nam (2017) give useful information for designing DPM-based intervention programs.

Limitations: DPM Application and Further Research Directions

Although we have linked the DPM parameters to the COVID-19 bereavement situation, we lack scientifically-based information. The listed LO and RO stressors have been quite consistently reported across different articles (see Supplementary File 1), but the extent to which these are experienced by bereaved persons is not yet known. Further identification of “at risk” subgroups is also needed. Many features of a COVID-19 death (or others occurring during - and therefore impacted by – the pandemic) are ones which have been recognized as risk factors, known to be associated with poor mental and/or physical health outcomes, such as a sudden or a traumatic death, lack of preparation for the death, one in intensive care, preexisting frailty, or lack of social support in general (see Stroebe et al., 2007). Thus, one could expect increases in grief complications and other health difficulties. However, this prediction needs to be established (or refuted) through sound empirical investigation, which will take time.

At the present state of knowledge, assumptions about negative consequences of COVID-19 bereavement experience also need to be made with caution and with reference to additional bodies of knowledge. It is known that most bereaved people in non-pandemic circumstances are resilient (Bonanno, 2004). Not all bereaved will suffer negative and/or lasting consequences, although it is to be expected, based on accumulated scientific evidence, that a small but significant number will get stuck in their grief – “derailed” as some describe it – and need intervention: “Though we are often heartened by human resilience, in response to death and other hardships, for some, the burden of this pandemic will be too much (Goveas & Shear, 2020, p. 1)”. Further studies need to establish how robust bereaved people are.

Another line of research needs to be taken into account when making to predictions about bereavement adjustment following the pandemic. The detrimental impact of enforced, abbreviated body disposal ceremonies has been highlighted in our previous sections. Again, it remains to be seen precisely what the impact is. Are these imposed cuts as harmful as one might be led to think? Are funeral-related activities as determining of grief over time as other established risk factors? Evidence from recent studies – in non COVID-29 circumstances – suggests that the type of ceremony may not be so critical to bereavement outcome. Studies have not shown significant relationships between elaborateness of funerals with grief and grieving over time (Birrell et al., 2020; Burrell & Selman, 2020; Mitima-Verloop et al., 2019). Whether or not such findings are replicated in the case of pandemic restrictions - with the notable difference that the regulations are enforced, not chosen - is again an empirical question for further investigation.² Could the lack of personal control over ceremonials, while having a negative impact, potentially also have some positive one too (it was beyond my control, I can’t be blamed, I am not guilty)?

There is another potential determinant relating to ceremonies: Some of the reviewed COVID-19 bereavement articles reported that alternatives had been created for lost ceremonials and meetings. Every manner of creative alternative has sprung up. One reads of many innovative, virtual initiatives, or of ones that provide consolation and deepened awareness in many shapes and forms (e.g., new or delayed ceremonies, national memorial days, special support groups, people pulling together, financial compensation programs). These may – or may not - compensate for the loss of traditional ceremonial occasions. Again, this is a research question needing investigation: do creative solutions to dealing with the restrictions mitigate negative effects?

Turning to establishing relationships between stressors, coping strategies and outcomes: These too have been based more on expert opinions and/or findings from earlier epi- or pandemics; natural disasters; ICU death experience, etc., rather than on empirical evidence from COVID-19 bereavement research (which will come in due course). It is too early in the course of the pandemic for longitudinal studies to have been conducted (e.g., to demonstrate cause and effect relationships between the implementation of societal measures to curtail the spread of the virus and grief and grieving). Nevertheless, some of the postulated relationships are intuitively plausible and they can be put to the test.

Final words. Bereaved people in COVID-19 bereavement situations have to face different or additional stressors and sometimes have to cope with them in novel ways, different from those which we have previously illustrated in our descriptions of the DPM. The landscape of grief and grieving emerges as changed in significant ways from pre-COVID-19 times. Using the model’s framework, we were able to summarize these features in DPM terms. We hope to have shown some uses of the model and to have illustrated that theoretical approaches have relevance to understanding the COVID-19 bereavement experience.

However, ours is only one among a number of theoretical approaches which have been developed to comprehend manifestations and phenomena of grief and grieving, as well-illustrated in the articles by Solomon and Hensley (2020) and Walsh (2020), reviewed earlier. We saw that Kübler-Ross’s DABDA stage model (Kübler-Ross & Kessler, 2005) featured in a couple of articles. A further word is in order regarding this model. We have cautioned against the use of its so-called DABDA (denial, anger, bargaining, depression, acceptance) stages (Stroebe et al., 2017). With respect to model in COVID-19 bereavement situations, our concern can be demonstrated with a single example. The authors of one of the reviewed articles echoed Kübler-Ross in stating that for those grief-stricken during the pandemic:“We have to inform survivors that anger is a necessary stage of the healing process and they must be willing to feel their anger, even though it may seem endless (Mortazavi et al., 2020, p. 228)”. There is no scientific evidence that anger is an essential reaction to bereavement under any circumstances, COVID-19-related or otherwise; such statements lead to false expectations.

Undoubtedly, though, other models could be subjected to a similar process of application to the COVID-19 bereavement situation, bringing unique insights. For example, Neimeyer’s (e.g., Neimeyer, 2001; see also Solomon & Hensley, 2020) meaning making approach would provide a useful framework for looking further into appraisal processes and their associations with adaptation to loss in pandemic circumstances. Such models also demonstrate the relevance of theoretical approaches to bereavement practice; further explorations of different perspectives could bring these two fields closer together, with mutual benefit.

Author Biographies

Margaret Stroebe is professor Emeritus, working at the University of Groningen and Utrecht University, the Netherlands. She has specialized in the field of bereavement research for many years, collaborating with colleagues on theoretical approaches to grief and grieving, reviewing the scientific literature (e.g., in 3 handbooks), and conducting empirical studies (e.g., interactive patterns of coping).

Henk Schut is associate professor of Clinical Psychology at Utrecht University, the Netherlands. His research interests cover processes of coping with loss and the efficacy of bereavement care and grief therapy. He also supervises postacademic clinical psychologists in their research interests. With Margaret Stroebe he developed the Dual Process Model of Coping with Bereavement.