Harnessing social support for bereavement now and beyond the COVID-19 pandemic.

The need to connect with others after loss is almost universal yet societies are more fragmented, lonely, and physically distanced than ever. Bereavement during COVID-19 – whether due to the pandemic or not – is accompanied by losses of income, routine, freedom, trust in others, future plans, and social support.[1] The current global crisis is expected to complicate grieving individuals’ adaptation to bereavement due to physical distancing during dying and death, diminished access to mourning rituals, and reductions in physical social support.[2,3] Policies aimed at addressing the pandemic underscore the urgent need to understand how individuals and communities can learn to provide social support to grieving persons as they manage these multiple losses.[4]

Social support is the perception or experience of being cared for, esteemed, and part of a mutually supportive social network.[5] Social support is typically provided by family members, friends, work colleagues, and neighbours and can be of different types (e.g. emotional, informational, instrumental).[6] Bereaved people much more commonly seek support from family and friends than from professionals, yet a considerable minority of grieving persons (almost one-third) report not receiving the support they would have liked.[7] It is commonly assumed that social support buffers the impact of bereavement but the evidence for this is mixed.[8] However, when social support is perceived by the recipient as helpful, it is one of the strongest determinants of positive psychosocial outcomes after bereavement[9] and protects against pervasive grief and depression.[10]

Social support is a complex process. A potential supporter must recognise the need for support. The support must be available, sufficient, and offered to the bereaved, and then perceived as helpful by the recipient. In addition, the usefulness can depend on the source, type, and timeliness of the support offered[6] and the receiver’s receptiveness to social support.[11] Bereaved people seek support from family and friends at a much greater rate than from professionals, yet often, the social support process goes awry. Some bereaved people report members of their social networks avoiding them, making hurtful comments, asking harmful questions, joking about the loss, offering platitudes, and generally lacking compassion.[6,12] Bereaved individuals also report expressing difficulties with recognising and expressing their support needs, seeking support from others, and accepting offers of support.[13] Likewise, the recognition of a need for support does not always lead to an offer of support.[14] Some potential supporters might feel uncertain about what support to offer in times of loss or worry that a support attempt might infringe on a recipient’s privacy.[15]

The complex social support process is likely to be influenced by three factors. First, norms are the rules that govern acceptable behaviour. For instance, research shows that prevailing social norms often undermine the giving, seeking, and accepting of social support at end-of-life.[15] Second, public stigma is the disapproval and discrimination of others and is influenced by prevailing norms. For example, public stigma is observed in experimental studies using vignette descriptions of grieving persons[14,16-19]but how stigma might affect the offer of social support is not known. The third component is grief literacy, which comprises knowledge to facilitate understanding of grief and loss, skills to enable supportive action, and values of compassion and care.[20] How these factors might influence the social support process is illustrated in Figure 1.

Figure 1.

The Complexities of Social Support Following Loss.

Despite the potential of social support to transform the lives of grieving persons, surprisingly little is known about how it might be optimised. A recent systematic review of factors determining supportive behaviours following bereavement identified 42 variables related to the griever, the deceased, and the potential supporter.[21] The authors highlighted substantial methodological flaws (e.g. student samples as proxies for the general community, numerous biases, limited controls, poor study quality) within this body of research. Furthermore, the transferability of knowledge is limited because the majority of studies (34 of 42) come from the United States. Two studies were from Japan and Australia, with one study from each of Ireland, Norway, United Kingdom, and Spain. Thus, the research has neglected diversity issues and cross-cultural complexities in social support.

The current milieu of loss and grief underscores the urgent need to understand substantially more about how top promote social support for grieving persons. Such knowledge is underdeveloped yet increasingly relevant in the wake of ‘everyday’ tragedies and large-scale events such as terrorism, newsworthy tragedies, natural disasters, and pandemics. Most bereavement care intervention efforts are targeted to addressing the needs of people with mental health concerns. However, health services are not necessarily well-equipped to identify bereaved individuals or provide appropriate bereavement care to the rising number of persons in need.[2] The COVID-19 crisis provides the opportunity to focus on developing social support, now and in the future, so that our communities are equipped to provide responsive, timely, and sustainable social support. Understanding the giving, seeking, and accepting of social support is critical to investigate how social support can be bolstered is critical to benefit grievers, their supporters, and communities. The time is right for considerable investment in research to understand how social support can be optimised as part of the rapidly developing public health palliative care movement that aims to reclaim dying and death in the everyday lives of individuals and communities.[22]