Get Hardy

How to turn adversity to your advantage.

About Complicated Bereavement Disorder

When grieving worsens, rather than gets better.

Warren Schmidt: “Relatively soon, I will die. Maybe in 20 years, maybe tomorrow, it doesn’t matter. Once I am dead and everyone who knew me dies too, it will be as though I never existed. What difference has my life made to anyone?  None that I can think of. None at all.” (The Film About Schmidt (2004); IMDB.com)

Perhaps, you know the film About Schmidt that starred Actor Jack Nicholson as the sixty-six year old, recently widowed, retired insurance executive whose life takes a nose-dive just at the time when he was supposed to be sailing off in the sunset? Warren retires after decades of employment only to find that his coworkers quickly forgot him. And, as if this wasn’t hard enough, Warren’s wife Helen suddenly dies of a stroke. But, his grieving for Helen quickly turns to anger when he unearths from their closet a box containing love letters to her from his best friend, Ray Nichols. Warren’s grieving process gets very complicated. Everything he once believed to be true shatters, along with the identity that carried him through life thus far. He goes on a search for meaning that he ends up finding in Ndugu;  a six year old Tanzanian African boy whom he adopts and with whom he pours out his troubles.

Grieving the loss of a loved one tears open our hearts, our lives, and seems to make time stand still, as we search for ways to make sense of the loss and what it means to our whole lives. We cry, eat more or less, can’t sleep, long for our loved ones and wonder how we will ever be able to live without them. This is all normal in simple grief. We may even seek counseling to cope with our pain and loss, although simple grief is not a mental disorder. In time, with or without the help of a counselor, the painful and debilitating acute symptoms of grief largely resolve and we get on with our lives.

However, for some people, acute grief can gain a foothold and become a chronic, debilitating mental health condition that worsens over time, rather than gets better. This is called complicated grief (CG). Pre-existing mental health conditions, multiple stressors, emotional dependency, or substance abuse issues complicate the grieving process and increase the likelihood of a complicated bereavement disorder that may necessitate professional treatment.

Complicated Grief: Risk and Symptoms

Approximately 10 to 20% of bereaved persons have severe enough, unremitting reactions to loss that result in a complicated grieving process that may require treatment that includes prescription medication and counseling (Grief and DSM V). A history of clinical depression and anxiety, emotionally dependent relationship on the deceased, and alcohol and drug addiction are often in the background of people who have complicated grief.

During the first few months after a loss, many signs and symptoms of simple grief are the same as those of complicated grief, although for the latter, they linger and worsen. Complicated grief is a chronic, heightened state of mourning. Its symptoms can include:

  • Extreme focus on the loss and reminders of the loved one
  • Intense longing or pining for the deceased
  • Problems accepting the death
  • Numbness or detachment
  • Preoccupation with your sorrow
  • Bitterness about your loss
  • Inability to enjoy life
  • Depression or deep sadness
  • Trouble carrying out normal routines
  • Withdrawing from social activities
  • Feeling that life holds no meaning or purpose
  • Irritability or agitation
  • Lack of trust in others

Inside the Grieving Brain

The grieving process is unpredictable. Mourners’ movement between different stages of grief is much like a pinball machine. They bounce back and forth from shock, to depression, and back to shock again, until they are able to resolve their emotions and integrate the meaning of the loss into their lives. (Science Daily: Pinball as Model for Dealing With Grief ). This doesn’t mean that they ever forget their deceased loved ones. They are part of their memories, histories, and life meaning. And, even though they dearly miss them, they do not let their memories mentally undermine them. They know there are other people who need their care, attention, and love and come to accept that their loved one has died. They have found a loving space within themselves for their memories of the deceased that do not let the loss take over their whole lives.

In contrast, complicated grievers interminably bounce back and forth through the stages of grief without resolution. Research findings show that their brains process grief differently from those who are able to resolve the loss of a loved one. The difference seems to be in the style of yearning their lost loved ones and inhopelessness for the future that prevents them from sufficiently working through the grieving process (Clinical Psychological Science Journal).

Complicated grievers remember the past and imagine the future through a distressed yearning for the deceased, hopelessness about the future, waves of painful emotion, and preoccupation with memories of the deceased. This intense preoccupation makes it difficult for them to recall past and future events that do not include the deceased loved one. It is like all other memories that do not include the deceased are erased from their minds. They only focus on significant past life events in which the deceased was alive (for example, birthdays, anniversaries, and their deaths). And, reflections on the future solely center on what life would be like if the deceased loved one was still with them.

It’s normal to yearn the loss of a loved one. For a time, we may look for the deceased in a crowd, momentarily reach for the phone to call them, expect them to come home, and surround ourselves with their pictures and belongings. But, these yearning reactions dissipate as mourners work through their feelings about the loss and integrate the loss into their lives.

But, complicated grievers (CG) keep the yearning process alive through theirhabits. They may create shrines of the deceased, constantly look at their pictures, or talk about them constantly. What’s significant here is that CG do not permit space in their lives for anything else but their memories of the lost loved one. Looking on, one might think they are addicted to the memories of the deceased.

In fact, addiction seems to play a role in complicated grief. Researcher O’Connor and colleagues searching for the neurological basis of grieving found that the intense yearning of complicated grievers brings them as much pleasure and reward as it does pain. In both simple and complicated grief, the center of the brain responsible for emotions and memories (limbic system) is activated. But, additionally, the MRI scans of complicated grievers show activation in the brain center responsible for pleasure, rewards, and addiction (nucleus accumbens).

Researchers concluded that the pleasure one gets from keeping the loved one alive reinforces the habits that prevent them from resolving their grief. Actually, pleasure derived from the grieving process might explain why people suffering complex grief are unable to get better over time  (The Daily Beast; Newsweek; 2008, Inside the Grieving Brain).

Help the Complicated Griever To Mourn

CG do not adequately mourn the loss of the loved one because they haven’t faced the reality of the loss. Preoccupation with the deceased and exclusion of activities and relationships that fall outside this preoccupation gives them enough subconscious pleasure to keep them stuck in the grieving process. They are feeling most certainly. But, their feelings emphasize more a wish to keep the person alive than an acceptance that the person is gone.

We can help CG to heal through a proper grieving process. We have to break the pleasure/pain cycle by altering their habits. Changes in thought and behavior, and meanings decrease intense yearnings to keep the deceased alive and gives hope for the future. Pre-existing mental health problems or alcohol or drug use that further complicate the loss also need to be addressed. Additionally, if medication is required it should treat the dopamine system that positively affects the pleasure/reward area of the brain, to sufficiently compete with the reward one is getting from staying stuck in the grieving process.

Talk therapycognitive-behavioral exposure therapy (Recent Trends in Treatment of Prolonged Grief), and meaning-oriented therapies (Dr. Paul Wong: International Network for Personal Meaningfacilitate the working through process and help people to incorporate the meaning of the death into their whole lives. Complicated grief therapies should include:

  1. Cognitive Behavioral Therapy: To resolve the death of a loved one, we need to examine thoughts that may be subconsciously giving us pleasure, by keeping a deceased loved one alive in our minds. CG have irrational thoughts around the loss. The death signifies an end of life rather than a life change, an intolerable experience rather than one that has to be managed and worked through, and a meaningless event rather than one that is full of meaning. This style of thinking actually gives as much pleasure as it does pain. These close-ended ideas shut down the possibility of getting better, which, strangely enough, subconsciously assures the griever that they do not have to let go of the deceased loved one. Changing their irrational thoughts to rational ones brings the reality of the loss into full awareness that decreases yearnings and weakens the pleasure/reward cycle.
  2. Exposure Therapy: Recall that mourners stuck in the grieving process exclude events from the past and musings about the future that do not include the deceased loved one. Therapies need to expose the grievers to all of the people and events that make up their lives. This, along with getting the griever to mark out times just for grieving, and also removing excessive reminders of the deceased loved one will do much to break habits that keep them stuck in the grieving process.
  3. Meaning Therapy: Nothing is changed without a change in meaning. The grief process necessitates that we make sense of the death through existing understandings and beliefs around death (For example, “I don’t understand why she died, but it is God’s will.”), or by accommodating the loss through meanings that reorganize, deepen, and expand our understandings into ourselves and life at whole (For example, “I need to learn to stand on my own two feet now without my beloved husband, wife, child, or sibling”.).

If a friend or loved one seems to have a complicated bereavement disorder, you don’t want to shake them out of their denial or tell them to snap out of it. The grief process needs to be carefully worked through. It takes time and professional skill to help them to face the loss, find meanings that give them hope for the future, and to re-engage them in relationships and activities that make them want to embrace life, once again.

Also, because the grief process can be complicated by depression, anxiety, posttraumatic stress disorder, or substance abuse, it’s best to see a professional counselor who can determine the right treatment. Sadly, some people do not get treatment and end up taking their own lives.

I hope you liked my post today and that you learned something new about the grieving process. If you did, please let me know by selecting the Like icon that immediately follows. You can also Tweet or Google+1 today’s post to let your friends and family know about it. Warmly Deborah.

Deborah Khoshaba, Psy.D., is a Clinical Psychologist and Director of Training and Development for the Hardiness Institute, Inc., Irvine, California, since 1989.

more...

Subscribe to Get Hardy

Current Issue

Let It Go!

It can take a radical reboot to get past old hurts and injustices.