The BNE four-tiered model

The Bereavement Network Europe (BNE) is interested in developing expert-agreed, internationally acceptable guidelines for bereavement care through a four-tiered approach, inspired by the evidence-based public health approach to bereavement care as advanced by NICE (UK), Samar M. Aoun, and others (2012, 2015, 2020). This three-tiered approach recognizes that while grief reactions vary from person to person, in general, bereavement care needs can be conceptualized as ranging from a need for basic information and support, through needing additional support and guidance, to needing a high level of specialized care.  A similar approach is currently being used by European Association for Palliative Care (Guldin et al., 2015).

The BNE four-tiered model of bereavement care corresponds to the research-based estimates that more than 60% of bereaved people experience a natural and healing grieving process, without requiring intervention beyond general support (tier 1). Approximately 40% of bereaved people experience a more difficult and drawn-out healing process, and may therefore need additional psychosocial support (tier 2 and 3). About 10% of these, experience that their grief remains intense and debilitating over a long period of time, and consequently require professional mental health intervention (tier 3; Bonanno et al., 2011; Lundorf et al, 2017).  Based on annual death statistics, it is  estimated that more than 8 million Europeans may need mental health support after the death of a loved one in a given year (Killikelly et al., 2021). 

This tiered approach to conceptualization of bereavement care needs, provides an effective structure for organizing and presenting information about bereavement intervention needs and resources.  

All four tiers are built upon a foundation of grief literacy, reflected in public understanding and professional education about the nature of bereavement.

BNE credits the Irish Hospice Foundation for developing the three tiered pyramid model of types of bereavement care, on which the BNE has expanded.

Tier 0 – Societal grief literacy
Death and bereavement are amongst the few certainties we have in life. At the same time our contemporary society conspires to make them invisible! Few policies outside of palliative care and suicide prevention talk about grief and bereavement. People admit to feeling unsure and awkward about how to approach people who are bereaved. Outdated models such as stage theory still dominate public thinking about normal bereavement. The base of the pyramid model identifies the importance of general public awareness, education and information about bereavement leading to a more compassionate society. This approach has been termed ‘grief literacy’ in recent literature. (Breen et al, 2020). We indicate this approach as Level 0 of the pyramid model.

Tier 1: General support & information
All bereaved people need support and information. The support can include both practical and emotional support. Informational needs can include information about grief in general, about available support and bereavement leave, and more. The bereaved person may receive this level of support in his/her family, social network and/or community.  Support and information may also be available through self-help and peer support groups, through the general practitioner, a social worker, other guidance personnel or volunteers.  Some information may be available from local and national organizations and online.

Tier 2: Extra Support
Bereaved persons at this level need additional support beyond the general support described in tier 1. For example, they may also need emotional support in the form of help with understanding their own reactions, exploring coping strategies, and developing new skills, while setting into a life without the deceased.  They may for example benefit from interventions that include meeting with a social worker, a support worker trained in bereavement care, a counsellor or a nurse, or with a trained clergy/chaplaincy.  They might also benefit from having the opportunity to share their experience with others in a similar situation, for example through a peer or facilitated support group.  Some interventions may be available through eHealth services.

Tier 3: Therapy support
At this level the bereaved person needs support and services beyond what has been available at tiers 1 and 2.  The bereaved person’s grief reactions and needs are complex and debilitating.  Some of them may meet criteria for psychiatric conditions such a depression and prolonged grief disorder.  Here professional services are needed, for example in the form of specialized psychotherapy. Some may require psychopharmacotherapy in addition to therapy.