Worden's task-based approach for supporting people bereaved by COVID-19.

Dying could be assumed as a developmental concomitant of living and a part of the birth-to-death continuum (Worden, 2018). Life might accompanied by several tragic deaths. Bereavement and grief represent the mental reactions of the survivors of a significant loss (Wallace et al., 2020). The expression “bereavement” stands for a universal experience of losing or loss, especially after the death of a loved one (Worden, 2018). Grief is also a cognitive process that requires confrontation with and restructuring of thoughts about the deceased, the experience of loss, and the altered world in which the survivor must now live. The process, known as grief work, includes basic tasks to be accomplished by the survivor for adapting to the loss (see Table 1; Worden, 2018). However, any “death loss” does not challenge these tasks in the same way (Worden, 2018). Specific features need to be addressed for supporting people bereaved through COVID-19 (Reja et al., 2020; Wallace et al., 2020). Unexpected death usually makes bereaved individuals have unreal feelings about the loss, probably lasting for a long time, e.g., walking around in a daze, numbness, and experiencing nightmares and intrusive images (Worden, 2018). Another feature is the growing need of survivors for understanding, which is often accompanied by the sense of blame (Worden, 2018). Since the very first question for people bereaved by COVID-19 is “why this happened?” (Wallace et al., 2020), survivors would strongly need to seek meaning in life, which requires to be thoughtfully incorporated in the third mourning task (Worden, 2018).

Table 1

Worden’s four-phase task model (Worden, 2018)

Task 1: Accept the reality of the loss This task deals with therapists’ efforts to assist the survivors with believing the impossibility of reunion, at least in this life. The searching behavior (broadly examined by Bowlby and Parkes) is directly connected to this task. There are paramount considerations, including denial of the loss facts, selective forgetting, mummification, religion spiritualism (i.e., the hope for a reunion with the deceased), denial of the death irreversibility, and “middle knowledge” (i.e., knowing and not knowing the loss simultaneously, as defined by Avery Weisman).

Task 2: Process the pain of grief The survivor needs to analyze the pain of loss to fulfill the pain process and inhibit suppressing or ignoring the pain. Survivors can prevent this task by not feeling, geographic cure, using alcohol or drugs, idealizing the deceased, and avoiding reminders of the deceased. Insufficient fulfillment of this task could then result in a more problematic return and pass the pain that has been inhibited.

Task 3: Adjust to a world without the deceased In this task, three realms of adjustment should be taken into account after a loss, including internal adjustments (the impact of the loss on one’s sense of self), external adjustments (the impact of the loss on one’s everyday functioning in the world), and spiritual adjustments (the influence of the loss on one’s values, beliefs, and assumptions about the world).

Task 4: help the survivors find an appropriate place for the deceased in their emotional life This task is intended to provide a place that helps the survivors to lead a fruitful life in the world. William Worden has interpreted this task as “finding a way to remember the deceased while embarking on the rest of one’s journey through life”.

As regards an unexpected loss, there is a wide range of symptoms categorized into four general groups, namely feelings, physical sensations, cognitions, and behaviors (Worden, 2018; Zisook and Shear, 2009). Nonetheless, grief is experienced differently by the bereaved individuals based on its intensity and duration (Bonanno and Kaltman, 2001). Thus, it is necessary to identify the mediators affecting these tasks to realize why people manage them differently, particularly for COVID-19-related bereavement (Wallace et al., 2020; Worden, 2018). Thus, in order to understand why people manage “mourning tasks” in different ways, it is necessary to identify the mediators that affect these tasks.

Six important mediators of mourning affecting the tasks of mourning were introduced by Worden (2018). As the first mediator, kinship with the deceased plays a key role in how the bereaved individuals respond to the loss. For example, adult children, widowers, and brothers of the deceased are less affected than parents (especially mothers), widows, and sisters (Worden, 2018). The quality of the survivor’s attachment to the deceased is the second mediator (Worden, 2018). In this regard, the depth of love for the deceased, conflict with the deceased, ambivalence about the deceased, the effectiveness of the deceased’s presence in the survivor’s sense of well-being, and dependent relationships (like pre-loss marital dependence) could determine the reaction to grief (Itzhar-Nabarro and Smoski, 2012). The third mediator is how the person died (Worden, 2018). In the COVID-19 crisis, the grief process could be altered based on the suddenness or unexpectedness of the death, the remoteness of the deceased at the moment of death, and multiple losses (Wallace et al., 2020). Historical antecedents constitute the fourth mediator, which include the quality of the survivor’s reaction to the previous losses, i.e., whether he/she has sufficiently mourned or added the prior unresolved grief to the new loss (Worden, 2018). Personality variables represent the fifth mediator (Worden, 2018). A recent study has revealed that grief reaction intensity increases under preexisting mood and anxiety disorders, maladaptive coping styles, preexisting trauma (particularly childhood trauma), rumination, insecure attachment styles, and negative cognitive styles (Eisma et al., 2020). The sixth mediator consists of social variables (Worden, 2018). The degree of emotional/social support from family or others plays a prominent role in the grief process, particularly under the effects of the COVID-19 pandemic (Farinha-Silva and Reis-Pina, 2020). Stigma, fear of contagion, and following lack of social support are among the challenges therapists face during the COVID-19 pandemic (Wallace et al., 2020). The last mediator involves concurrent stresses and losses (Worden, 2018), namely substance use, complex economic problems (due to the restricted business during quarantine or family head loss by COVID-19 infection), and inability to follow death and mourning rituals (Farinha-Silva and Reis-Pina, 2020; Wallace et al., 2020; Zhai and Du, 2020). Further, levels of survivors’ distress are clearly affected by various mediators (Wortman and Silver, 2001). Hence, therapists need to address these mediators to assist with the COVID-19-related bereavement issues.

All in all, as long as the COVID-19 pandemic persists, the grief caused by multiple losses will continue (Zhai and Du, 2020). It seems that paying attention to Worden’s task-based model during early months of bereavement can help therapists to support people bereaved by COVID-19. However, more extensive investigations need to be carried out in this field through randomized controlled trials.