📋 Key Information Summary
- Grief is a normal, individualised response to loss; its expression is shaped by culture, spirituality, relationship to the deceased, and circumstances of the death.
- Most bereaved people experience acute grief that gradually integrates over weeks to months without requiring formal intervention.
- Prolonged grief disorder (PGD) is now a recognised diagnosis in ICD-11 and DSM-5-TR; it affects approximately 7–10% of bereaved individuals and requires targeted treatment.
- PGD is characterised by persistent, pervasive longing or preoccupation with the deceased, marked functional impairment, and duration ≥ 12 months (≥ 6 months in DSM-5-TR).
- Depression and anxiety are common comorbidities of bereavement; they must be distinguished from normal grief and from PGD as treatment pathways differ.
- Routine bereavement follow-up is a core standard of palliative care in Australia (Palliative Care Australia Standards 2018); services should contact all bereaved families within a structured framework.
- Risk factors for complicated grief include sudden or traumatic death, loss of a child, insecure attachment style, limited social support, prior mental illness, and Aboriginal or Torres Strait Islander communities experiencing intergenerational trauma.
- Screening tools include the PG-13 (Prolonged Grief-13), the Inventory of Complicated Grief (ICG), and the Kessler-10 (K10) for depression/anxiety.
- First-line treatment for PGD is grief-focused psychotherapy (Complicated Grief Treatment or targeted CBT); pharmacotherapy with SSRIs is adjunctive for comorbid depression/anxiety.
- Anticipatory grief — grief experienced before the death — is clinically significant and should be validated and supported throughout the palliative care trajectory.
- Children and adolescents grieve differently from adults; developmentally appropriate communication and support are essential.
- Aboriginal and Torres Strait Islander bereavement practices are culturally specific; sorry business requires culturally safe, community-led approaches with avoidance of naming the deceased in some communities.
Introduction & Australian Epidemiology
Loss, grief, and bereavement are fundamental experiences encountered throughout palliative care. They affect not only the patient facing the end of life but also families, carers, friends, and the healthcare professionals providing care. Grief encompasses the emotional, cognitive, physical, social, and spiritual responses to any significant loss — including the anticipated loss of one's own life, the death of a loved one, and losses associated with declining function and independence.
In Australia, approximately 178,000 deaths occur annually (AIHW 2023), with each death profoundly affecting an estimated 5–10 close family members and friends. Palliative care services support over 100,000 Australians each year, yet bereavement follow-up remains inconsistent across jurisdictions and service models. The National Palliative Care Strategy (2018) identifies bereavement support as a core component of holistic end-of-life care.
This topic addresses grief before and after death — including anticipatory grief experienced by patients and families during the palliative trajectory, normal grief reactions, the distinction between normal grief and pathological grief states (prolonged grief disorder, depression, anxiety), and the structured approach to bereavement follow-up in Australian practice.
Australian context: The Australian healthcare system funds bereavement support through palliative care programs (Medicare-funded and state-funded), community mental health, and not-for-profit organisations such as Grief Australia, the Australian Centre for Grief and Bereavement (ACGB), and Palliative Care Australia. Aboriginal Community Controlled Health Organisations (ACCHOs) provide culturally specific grief and loss programs.
Normal Grief
Normal grief — sometimes termed uncomplicated grief or integrated grief — is the expected, adaptive response to loss. It is not a disorder; it is a human experience with significant biological, psychological, social, and spiritual dimensions.
Models of Normal Grief
Several theoretical models inform clinical understanding:
- Worden's Tasks of Mourning (1982, revised 2009): Four tasks — (1) accept the reality of the loss, (2) process the pain of grief, (3) adjust to a world without the deceased, (4) find an enduring connection with the deceased while embarking on a new life.
- Stroebe & Schut Dual Process Model (1999): Oscillation between loss-oriented coping (confronting the grief) and restoration-oriented coping (attending to life changes, new roles, distractions). Healthy adaptation involves movement between both.
- Kübler-Ross Five Stages (1969): Denial, anger, bargaining, depression, acceptance — widely known but not empirically validated as sequential stages; better understood as common emotional states that may occur in any order.
- Continuing Bonds Theory (Klass et al. 1996): Maintaining an ongoing internalised relationship with the deceased is normal and adaptive, rather than requiring emotional "detachment."
Clinical Features of Normal Grief
| Domain | Common Experiences |
|---|---|
| Emotional | Sadness, yearning, anger, guilt, anxiety, loneliness, relief (especially after prolonged illness), emotional numbness |
| Cognitive | Disbelief, confusion, preoccupation with the deceased, difficulty concentrating, sense of the deceased's presence, searching behaviour |
| Physical | Fatigue, sleep disturbance, appetite changes, somatic symptoms (chest tightness, "hollowness"), headaches, gastrointestinal upset |
| Behavioural | Social withdrawal, restlessness, crying, hyperactivity or lethargy, avoiding reminders or seeking them out |
| Spiritual | Questioning meaning and purpose, anger at God/higher power, renewed or diminished faith, existential distress |
Trajectory of Normal Grief
- Acute grief is most intense in the first weeks to months following bereavement.
- Most individuals show gradual improvement in functioning and emotional distress over 6–12 months.
- Grief does not "resolve" in the sense of being completed; rather, it becomes integrated — the loss is acknowledged and the bereaved person re-engages with life while carrying the memory of the deceased.
- Waves of intense grief may recur at anniversaries, holidays, or when triggered by reminders — this is normal and does not indicate pathology.
- Anticipatory grief, experienced before the death, can reduce the intensity of post-death acute grief but does not eliminate it.
Key principle: Normal grief requires validation, psychoeducation, and supportive listening — not pharmacotherapy or specialist referral. The role of the GP and palliative care team is to normalise the experience, provide information, monitor for complications, and offer ongoing support.
Prolonged Grief Disorder
Prolonged grief disorder (PGD) — previously termed complicated grief, pathological grief, or persistent complex bereavement disorder (DSM-5) — is now a formally recognised psychiatric diagnosis in both ICD-11 (6B42) and DSM-5-TR (2022). It represents a maladaptive grief response in which the normal process of integration is disrupted, leading to persistent, disabling symptoms.
Diagnostic Criteria
| Criterion | ICD-11 (6B42) | DSM-5-TR |
|---|---|---|
| Core symptom | Persistent and pervasive longing for or preoccupation with the deceased | Persistent longing/yearning and/or preoccupation with the deceased |
| Additional symptoms | ≥ 3 of: difficulty accepting death, emotional numbness, feeling life is meaningless, intense loneliness, marked difficulty in daily functioning | ≥ 3 of 6: identity disruption, disbelief, avoidance of reminders, emotional pain, difficulty re-engaging, emotional numbness, feeling life is meaningless, intense loneliness |
| Duration | ≥ 12 months after bereavement | ≥ 12 months after bereavement (≥ 6 months for children/adolescents) |
| Impairment | Significant impairment in personal, family, social, educational, occupational functioning | Clinically significant distress or functional impairment |
| Exclusions | Not better explained by another mental disorder, substance use, or medical condition | Not better explained by MDD, PTSD, substance use, or medical condition |
Epidemiology
- Prevalence: approximately 7–10% of bereaved adults develop PGD (Lundorff et al. 2017 meta-analysis).
- Higher rates (up to 15–20%) following violent or unexpected deaths, loss of a child, or among individuals with pre-existing psychiatric conditions.
- In Australian palliative care populations, PGD prevalence may be higher due to late referral, limited bereavement services in regional/rural areas, and the needs of Aboriginal and Torres Strait Islander communities.
Distinguishing Normal Grief from Prolonged Grief Disorder
Clinical distinction: In normal grief, painful emotions occur in waves and are interspersed with positive memories and periods of normal functioning. In PGD, the yearning is persistent and pervasive, functioning remains significantly impaired beyond 12 months, and the bereaved person feels "stuck" in acute grief with a sense that life cannot go on without the deceased.
Risk Factors for Prolonged Grief Disorder
| Category | Risk Factors |
|---|---|
| Circumstances of death | Sudden or unexpected death, violent or traumatic death, suicide, homicide, death of a child (perinatal loss or later) |
| Relationship factors | Highly dependent or insecure attachment, ambivalent or conflicted relationship, loss of a primary attachment figure (spouse, parent, child) |
| Individual factors | History of depression or anxiety, prior unresolved losses, low self-esteem, avoidant or anxious attachment style, limited coping repertoire |
| Social factors | Limited social support, financial hardship, caregiver burden, social isolation, culturally disenfranchised grief |
| Cultural factors | Inability to perform culturally required mourning rituals, intergenerational grief (e.g., Stolen Generations), marginalisation |
Treatment of Prolonged Grief Disorder
Evidence-based treatments include:
- Complicated Grief Treatment (CGT) — developed by Shear et al. (2014); the most robustly evidence-based psychotherapy. Involves dual-process work, revisiting the death narrative, imaginal conversations with the deceased, and situational exposure to avoided reminders. Superior to interpersonal psychotherapy in RCTs.
- Grief-focused CBT — cognitive restructuring of maladaptive grief appraisals (e.g., "I should have prevented the death"), behavioural activation, and graded exposure.
- Pharmacotherapy: No medication is specifically approved for PGD in Australia. SSRIs (particularly citalopram) have shown modest benefit in open-label studies and may be useful for comorbid depression/anxiety. Short-term benzodiazepines are NOT recommended due to dependence risk and interference with grief processing.
Sertraline
Zoloft® · Generic · SSRI
Adult dose
50 mg PO daily, titrate to 100–200 mg daily
Paediatric dose
Not indicated for PGD in children; MDD: 25–200 mg PO daily (≥ 6 years)
Renal adjustment
None required
Hepatic adjustment
Reduce dose or use with caution in severe hepatic impairment
PBS status
✔ PBS General Benefit
Citalopram
Cipramil® · Generic · SSRI
Adult dose
20 mg PO daily, max 40 mg daily
Paediatric dose
Not recommended < 18 years for this indication
Renal adjustment
Use with caution; no specific dose adjustment
Hepatic adjustment
Max 20 mg daily in hepatic impairment
PBS status
✔ PBS General Benefit
Do not prescribe benzodiazepines as grief therapy. Benzodiazepines may suppress emotional processing necessary for grief integration, carry dependence risk, and are associated with increased mortality in bereaved elderly populations. Reserve for acute, severe distress in supervised settings only (e.g., acute psychiatric crisis).
Depression & Anxiety in Bereavement
Depression and anxiety are common in bereaved individuals and may coexist with normal grief, prolonged grief disorder, or represent independent psychiatric diagnoses requiring specific treatment.
Distinguishing Grief from Major Depressive Episode
| Feature | Normal Grief | Major Depressive Episode |
|---|---|---|
| Predominant affect | Emptiness, yearning, waves of sadness | Persistent low mood, anhedonia (inability to feel pleasure) |
| Self-esteem | Generally preserved | Often impaired — worthlessness, self-loathing |
| Positive emotions | Can still experience warmth, humour, positive memories | Pervasive anhedonia; difficulty experiencing any positive affect |
| Content of thoughts | Preoccupation with the deceased; may include self-reproach related to the deceased | Global negative self-evaluation; hopelessness about the future; suicidal ideation (death wish beyond "wanting to be with" deceased) |
| Course | Waxing and waning; gradual improvement | Persistent and pervasive; does not remit without treatment |
| Functional impairment | Fluctuating; periods of normal function | Sustained; inability to work, care for self, maintain relationships |
Bereavement-Associated Anxiety
- Generalised anxiety about the future, health of remaining family members, and financial security is common.
- Separation anxiety: Fear of being alone, hyper-vigilance about safety of others, reluctance to let family members leave the house.
- Health anxiety: Heightened awareness of own mortality, somatic preoccupation, fear of developing the same illness as the deceased.
- Trauma-related symptoms: Intrusive images of the death (especially if witnessed), nightmares, hyperarousal — particularly after traumatic or witnessed deaths. Consider comorbid PTSD.
Pharmacological Management
Pharmacotherapy is indicated when major depressive disorder or generalised anxiety disorder is diagnosed — not for normal grief alone.
Sertraline
Zoloft® · First-line SSRI for MDD/GAD
Adult dose
50 mg PO daily, titrate to 100–200 mg daily
Onset
2–4 weeks for initial response; full effect 6–8 weeks
Key cautions
Suicidality monitoring in first weeks; serotonin syndrome with tramadol/MAOIs; GI bleeding risk with NSAIDs
PBS status
✔ PBS General Benefit
Mirtazapine
Avanza® · Generic · NaSSA
Adult dose
15 mg PO nocte, titrate to 30–45 mg nocte
Role in bereavement
Particularly useful when insomnia, anorexia, and weight loss are prominent features of bereavement-related depression
Key cautions
Sedation (especially at lower doses), weight gain; caution in elderly — fall risk
PBS status
✔ PBS General Benefit
Previously "bereavement exclusion" removed: The DSM-5 removed the bereavement exclusion that previously prevented diagnosis of MDD within the first 2 months of bereavement. Clinicians must now use clinical judgement to distinguish grief from MDD at any time point after the loss. The presence of functional impairment, anhedonia, suicidal ideation, and global negative self-appraisal should prompt consideration of MDD even in recently bereaved individuals.
Bereavement Follow-Up
Structured bereavement follow-up is a core component of palliative care and is mandated by the Palliative Care Australia Standards (2018). It encompasses risk assessment, proactive contact, psychoeducation, and targeted intervention for those who develop complications.
Framework for Bereavement Follow-Up
Pre-death
Anticipatory bereavement assessment — Identify risk factors during palliative care admission. Flag high-risk families for enhanced post-death follow-up. Provide anticipatory grief support and psychoeducation. Document bereavement plan in care notes.
Within 2 weeks
Initial contact — Phone call, letter of condolence, or home visit from the palliative care team, GP, or bereavement counsellor. Assess immediate coping, safety, social supports, and need for further contact. Provide written grief information resources.
1–3 months
Follow-up contact — Phone call or scheduled appointment. Assess emotional adjustment, functional status, sleep, appetite, use of alcohol or substances. Screen with validated tools (PG-13, K10). Offer ongoing counselling or peer support referral.
6 months
Structured review (high-risk families) — Formal assessment for prolonged grief disorder, depression, and anxiety. Referral to specialist grief counselling or mental health services if indicated. Consider letter or phone call on significant dates.
12 months
Annual review / anniversary contact — Letter or phone call marking the anniversary. Re-assess for PGD (now meeting diagnostic criteria if ≥ 12 months). Offer further support or closure of bereavement service as appropriate.
Screening Tools for Bereavement
Essential
PG-13 (Prolonged Grief-13)
13-item self-report measure; gold standard for PGD screening. Validated in Australian populations. Scores ≥ 25 indicate probable PGD. Free to use; available from the Center for Prolonged Grief (Columbia University).
Available
Inventory of Complicated Grief (ICG)
19-item self-report instrument; scores > 25 associated with clinically significant complicated grief. Validated in multiple populations including Australian studies.
Available
Kessler-10 (K10)
10-item screening for psychological distress (depression and anxiety). Scores ≥ 22 suggest high-level distress requiring specialist referral. Widely used in Australian primary care; freely available.
Available
Patient Health Questionnaire-9 (PHQ-9)
9-item depression screening tool; scores ≥ 10 indicate moderate depression. Used in Australian primary care; MBS item 701 (GP Mental Health Treatment Plan) may apply when diagnosed.
Who Is at Higher Risk? (Bereavement Risk Stratification)
Palliative care services should conduct a bereavement risk assessment at the time of patient admission and again at the time of death. High-risk families require enhanced follow-up.
Lower Risk
Standard Follow-Up
Expected death after chronic illness, adequate social supports, no prior psychiatric history, healthy coping, culturally congruent mourning possible.
Setting: Condolence letter + phone call at 4–6 weeks; written resources
Moderate Risk
Enhanced Follow-Up
History of depression or anxiety, limited social supports, complicated relationship with deceased, carer exhaustion, financial stress, elderly living alone.
Setting: Phone call at 2 weeks + 3 months; offer GP review; screen with K10/PG-13
High Risk
Intensive Follow-Up
Sudden or traumatic death, suicide bereavement, loss of a child, pre-existing mental illness, substance use, Aboriginal/Torres Strait Islander communities affected by intergenerational trauma, family conflict, sole carer.
Setting: Pre-death meeting + contact at 1 week, 1 month, 3 months, 6 months, 12 months; specialist referral
Services & Referral Pathways in Australia
- Grief Australia / Australian Centre for Grief and Bereavement (ACGB): National counselling, education, and support services. Phone: 1800 642 066.
- beyondblue / Beyond Blue: 1300 22 4636 — depression and anxiety support relevant to bereavement-related mood disorders.
- Lifeline Australia: 13 11 14 — crisis support for bereaved individuals experiencing suicidal ideation.
- StandBy Support After Suicide: National program for people bereaved by suicide.
- Palliative Care Australia: Directory of palliative care services by state/territory. palliativecare.org.au
- SIDS and Kids / Red Nose: Bereavement support for families affected by stillbirth, SIDS, or childhood death.
- GP Mental Health Treatment Plan (MBS item 701/703): Enables Medicare-rebated psychological treatment (up to 10 sessions/year, extended to 20 during COVID-era provisions).
Anticipatory Grief
Anticipatory grief is grief experienced before the death — by the patient, family members, and carers — in the context of a life-limiting illness. It is a normal but often overlooked dimension of palliative care.
Features of Anticipatory Grief
- Patient: mourning the loss of their own future, roles, identity, independence, and relationships.
- Family/carer: mourning the impending loss of the loved one, the changing relationship, loss of shared future plans, and their own role changes.
- May include sadness, anxiety, anger, guilt, preoccupation with the future, emotional distancing, and premature withdrawal from the patient.
- Can be disenfranchised by well-meaning statements such as "at least you have time to prepare" or "be strong for them."
Supporting Anticipatory Grief
- Normalise the experience — validate that grief before death is real grief and does not imply abandonment or disloyalty.
- Encourage open communication within families about fears, wishes, and practical matters (advance care planning).
- Facilitate meaningful activities — creating legacies (letters, memory boxes, photo collections), reconciliation conversations, and saying goodbye.
- Acknowledge the dual burden for carers: grieving while simultaneously providing care.
- Offer referral to palliative care social work or counselling services during the palliative phase, not only after death.
Clinical tip: Anticipatory grief does not "replace" post-death grief. Even when families have had time to prepare, the finality of death triggers a distinct grief response. Never assume that a prolonged illness trajectory means the family will cope more easily after the death.
Pharmacological Considerations in Grief-Related Distress
Pharmacotherapy has a limited but important role in the management of bereavement-related psychiatric conditions. Medications are indicated for diagnosed depression, anxiety disorders, or insomnia — not for normal grief itself.
The Australian & New Zealand College of Psychiatrists (RANZCP) position: Pharmacotherapy should not be used as a substitute for psychosocial support in grief. Prescribing for grief alone (without a psychiatric diagnosis) is not recommended and may pathologise a normal human experience.
Melatonin
Circadin® · Prolonged-release
Adult dose
2 mg PO 1–2 hours before bedtime (1–3 weeks initially)
Role
Short-term management of bereavement-related insomnia; preferred over benzodiazepines or Z-drugs; lower risk of dependence
Key cautions
Drowsiness; caution with hepatic impairment
PBS status
▲ PBS Authority Required (age ≥ 55, insomnia ≥ 4 weeks)
Hydroxyzine
Atarax® · Seda-Tabs® · Sedating antihistamine
Adult dose
25 mg PO TDS PRN for acute anxiety (short-term only)
Role
Short-term anxiolytic for acute bereavement-related anxiety when benzodiazepines are to be avoided; non-addictive
Key cautions
Anticholinergic effects; caution in elderly; QTc prolongation at higher doses
PBS status
✔ PBS General Benefit
Special Populations
Paediatrics
Children grieve differently from adults; expression varies by developmental stage.
Pre-school children may show regression, bedwetting, clinging behaviour, and magical thinking (e.g., "if I'm good, mummy will come back").
School-age children may show anger, guilt, school refusal, somatic symptoms, and repetitive questioning about the death.
Adolescents may show risk-taking behaviour, substance use, academic decline, social withdrawal, or premature assumption of adult roles.
Use honest, age-appropriate language; avoid euphemisms ("lost," "went to sleep") that may cause confusion or fear.
Include children in mourning rituals if they wish to participate; do not force or exclude.
Referral to paediatric psychology or specialist grief programs (e.g., Seasons for Growth, Feel the Magic) for complex presentations.
Elderly
Older adults may experience cumulative losses (spouse, friends, siblings, independence, health, home).
Grief may be complicated by sensory impairment, cognitive decline, social isolation, and co-morbid medical conditions.
Depression in bereaved elderly is frequently under-recognised; somatic presentations (fatigue, pain, appetite loss) may be attributed to ageing or medical illness.
Bereaved elderly men have increased mortality in the first 6 months after spousal loss ("broken heart" phenomenon); monitor cardiovascular health.
Use lower doses of psychotropic medications; sertraline is preferred SSRIs in the elderly (fewer drug interactions). Monitor for hyponatraemia, falls, and bleeding.
Encourage maintenance of social connections, community groups, and structured activities.
Pregnancy & Perinatal Loss
Perinatal loss (miscarriage, stillbirth, neonatal death) is a significant bereavement event affecting 1 in 4 pregnancies (miscarriage) and ~3,000 Australian families annually (stillbirth ≥ 20 weeks).
Grief may be disenfranchised by society ("at least it was early," "you can try again"); validate the loss.
Both parents are affected; fathers' grief is often overlooked. Siblings also grieve.
Red Nose (formerly SIDS and Kids) provides bereavement support for perinatal loss including memory-making (photographs, hand and footprints, keepsakes).
Screen for postnatal depression (Edinburgh Postnatal Depression Scale) and PTSD in subsequent pregnancies.
If pharmacotherapy is needed during subsequent pregnancy, sertraline is preferred SSRI (limited placental transfer; safety data available).
Renal Impairment
Patients on dialysis experience repeated losses (loss of health, independence, employment, body image from vascular access).
Renal patients may have altered drug metabolism; adjust antidepressant doses accordingly.
Sertraline is generally safe in renal impairment (no dose adjustment required); avoid citalopram at doses > 20 mg due to QTc risk.
Integrate bereavement support into dialysis unit routines; leverage existing therapeutic relationships.
Hepatic Impairment
Reduce doses of hepatically metabolised antidepressants in liver disease.
Sertraline: use with caution, consider dose reduction in severe impairment.
Mirtazapine: reduce dose in hepatic impairment; monitor LFTs.
Avoid benzodiazepines (risk of hepatic encephalopathy and oversedation).
Immunocompromised
Grief-related stress and depression are associated with immunosuppression, which is clinically relevant in transplant recipients, HIV-positive individuals, and those receiving chemotherapy.
HIV-positive individuals may face cumulative losses and community grief (legacy of the AIDS epidemic); culturally sensitive support is essential.
Drug interactions: SSRIs may interact with antiretrovirals (particularly ritonavir-boosted regimens); consult infectious disease pharmacist. Sertraline and escitalopram are preferred.
Non-Pharmacological Interventions
Psychosocial and non-pharmacological interventions form the mainstay of grief support and are the first-line treatment for prolonged grief disorder.
1
Psychoeducation
Normalise grief reactions; explain the dual-process model; provide written information; set realistic expectations about the grief trajectory.
2
Supportive Listening
Active, empathic listening without premature reassurance. Use the deceased person's name. Allow silence. Avoid clichés ("they're in a better place," "everything happens for a reason").
3
Peer Support & Groups
Grief support groups (face-to-face or online) offered by ACGB, palliative care services, and community organisations. Peer support reduces isolation and normalises the experience.
4
Complicated Grief Treatment (CGT)
Evidence-based, manualised psychotherapy for PGD. Involves dual-process oscillation work, revisiting the loss narrative, imaginal dialogues, situational exposure, and restoration-focused goal setting. 16 sessions over approximately 4 months.
5
Cognitive Behavioural Therapy (CBT)
Targets maladaptive grief cognitions (e.g., catastrophic guilt, rumination); behavioural activation; graded exposure to avoided situations. Delivered by psychologists under MBS items 80010/80011 or via GP Mental Health Treatment Plan (MBS 701).
6
Spiritual Care
Address existential distress, meaning-making, and spiritual needs. Refer to hospital chaplaincy, pastoral care, or community spiritual leaders as appropriate to the individual's beliefs.
Self-care for clinicians: Healthcare professionals in palliative care are at risk of compassion fatigue, moral distress, and burnout. Regular clinical supervision, reflective practice, Schwartz Rounds (available in many Australian hospitals), and institutional support for staff wellbeing are essential components of a sustainable bereavement care model.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Bereavement in Aboriginal and Torres Strait Islander communities occurs within a context shaped by colonisation, the Stolen Generations, intergenerational trauma, systemic racism, and ongoing health inequities. Grief and loss are experienced collectively, and mourning practices (sorry business) are deeply embedded in cultural and spiritual life.
Key Cultural Considerations
- Sorry business: A culturally specific process of mourning that may involve extended community gatherings, ceremonial practices, smoking ceremonies, and communal grieving lasting days to weeks. It is a collective responsibility, not an individual one.
- Avoidance of the deceased person's name: In many Aboriginal communities, it is customary to avoid speaking the name of the deceased or using similar-sounding words. Healthcare workers must respect this practice and modify documentation and communication accordingly.
- Avoidance of images and recordings: Photographs or recordings of the deceased may need to be removed or restricted. Seek guidance from the family and community.
- Skin name and kinship: Mourning obligations and restrictions vary by kinship group, skin name, and community. Some family members may have specific roles in sorry business that require their absence from other obligations.
- Cumulative grief burden: Aboriginal and Torres Strait Islander Australians experience significantly higher mortality rates (AIHW 2023), leading to cumulative, compounded grief across the lifespan. The average age of death is approximately 8 years lower for Indigenous Australians, with disproportionate burden of chronic disease, suicide, and infant mortality.
- Suicide bereavement: Suicide rates among Aboriginal and Torres Strait Islander peoples are approximately twice the national rate, with youth rates significantly higher. Suicide bereavement carries particular cultural and spiritual significance and requires specialist, culturally informed response.
Barriers to Bereavement Support
Recommended Approaches
- Engage Aboriginal and Torres Strait Islander health workers and liaison officers in all bereavement care planning and delivery.
- Fund and support grief and loss programs delivered by Aboriginal Community Controlled Health Organisations (ACCHOs), such as those coordinated by the National Aboriginal Community Controlled Health Organisation (NACCHO).
- Respect sorry business as a legitimate, therapeutic cultural practice — do not attempt to substitute or supplant it with Western grief counselling models.
- Use the Social and Emotional Wellbeing (SEWB) framework (developed by the Healing Foundation) rather than a purely biomedical mental health model when assessing grief in Indigenous communities. SEWB encompasses connection to body, mind and emotions, family and kinship, community, culture, Country, and spirituality.
- Support community-led memorial events, art-based healing programs, and on-Country mourning where possible.
- Ensure all bereavement resources and screening tools are culturally validated for Indigenous populations before use.
Important: Western diagnostic categories (PGD, MDD) were developed in non-Indigenous contexts. While they may be useful, they should not be applied rigidly without cultural consultation. The expression of grief, distress, and healing in Aboriginal and Torres Strait Islander communities may not align with Euro-Western constructs. Always seek guidance from Aboriginal health professionals and community Elders.
📚 References
- 1. World Health Organization. Palliative care fact sheet. Geneva: WHO; 2020. Available from: who.int
- 2. Prigerson HG, Boelen PA, Xu J, et al. Prolonged grief disorder: an integrative consensus diagnosis for ICD-11 and DSM-5-TR. JAMA Psychiatry. 2021;78(7):688–698.
- 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev. Washington DC: APA; 2022. Prolonged Grief Disorder.
- 4. World Health Organization. ICD-11 for Mortality and Morbidity Statistics. 6B42 Prolonged Grief Disorder. Geneva: WHO; 2024.
- 5. Shear MK, Ghesquiere A, Glickman K. Bereavement and complicated grief. Curr Psychiatry Rep. 2013;15(11):406.
- 6. Shear MK, Reynolds CF, Simon NM, et al. Optimizing treatment of complicated grief: a randomized clinical trial. JAMA Psychiatry. 2016;73(7):685–694.
- 7. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description. Death Stud. 1999;23(3):197–224.
- 8. Worden JW. Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner. 5th ed. London: Routledge; 2018.
- 9. Lundorff M, Holmgren H, Zachariae R, et al. Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. J Affect Disord. 2017;212:138–149.
- 10. Palliative Care Australia. National Palliative Care Standards. 5th ed. Canberra: PCA; 2018.
- 11. Australian Institute of Health and Welfare. Deaths in Australia. AIHW; 2023. Cat. no. PHE 232.
- 12. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework. AIHW; 2023. Cat. no. IHW 222.
- 13. Healing Foundation. Social and Emotional Wellbeing Framework. Canberra: Healing Foundation; 2020.
- 14. Klass D, Silverman PR, Nickman S, eds. Continuing Bonds: New Understandings of Grief. Washington DC: Taylor & Francis; 1996.
- 15. Jordan AH, Litz BT. Prolonged grief disorder: diagnostic, assessment, and treatment considerations. Prof Psychol Res Pr. 2014;45(3):180–187.
- 16. Red Nose (formerly SIDS and Kids). National bereavement support resources. Available from: rednose.org.au