Skip to main content

Verified by Psychology Today

Grief

The Trouble With 'Complicated Grief'

Is it ever possible - or helpful - to label someone' grief process abnormal?

What’s known for certain about so-called ‘complicated grief’?

Well, at risk of stating the obvious, what’s known for certain is that it’s complicated.

Broadly, complicated grief is a pretty well recognised phenomenon. It’s common knowledge that people can get ‘stuck’ in mourning, and that counselling or therapy may help them ‘move through’ or ‘process’ their grief. If you pick a few people on the street at random, they can probably give a rough explanation of what ‘complicated grief’ looks like.

However, ‘complicated grief’ has no universal diagnostic criteria.
It has no standard definition.
It does not even have an officially sanctioned name.
Indeed, debate still rages over whether to consider it a 'disorder' at all.

Complicated grief is currently listed among conditions for which further attention and research is required in the DSM-5, under the working label ‘Persistent Complex Bereavement Disorder’.

Why is complicated grief so difficult to quantify? Because it’s a phenomenon defined not by the presence of observable symptoms, but by the absence of ‘normality’.

To see what I mean, let’s take a look at the full range of ‘normal’ grief responses after a significant bereavement. There’s overwhelming sadness and despair on the list, of course. On the other hand there’s also numbness, emptiness, and the inability to feel. It’s normal to isolate yourself. It’s also normal to become more dependent on others and not want to be alone.
Nightmares, insomnia and exhaustion are normal – but so is oversleeping.
Weight loss is normal. Weight gain is normal.
The list goes on, a patchwork of opposites that features huge swathes of the emotional and psychological spectrum.

Because pretty much everything fits the definition of ‘normal’ in the wake of devastating loss, we tend to use the passage of time to determine the presence of complicated grief. Typically, the symptoms described above largely resolve by 18 months post-loss, and therapy appears to have little to no benefit in speeding up the process. But for around 10-20% of bereaved individuals, symptoms persist or worsen over time. These are the people that fit the picture of complicated grief as we currently understand it.

Seems simple enough, right? Complicated grief is present when the effects of bereavement persist over too much time.

Well, not really. Because how does one quantify ‘too much time’?

While there is considerable anthropological evidence that all humans endure some form of pain following the loss of a loved one, beliefs about death and mourning vary enormously between individuals, circumstances, cultures and societies.

‘Grief’ quite literally has no translation in some cultures, with the bereaved expected to transition quickly back to normality. Grievers may be ‘policed’ by others in such cultures to put on a smile, and even teased and jollied.

On the other hand, in some cultures ‘moving on’ is seen as neither normal nor desirable. There is no belief that one will or should ever recover from the loss, and what's expected for people in these cultures closely resembles Western society’s picture of ‘complicated grief’.

In yet other cultures, the dead are seen as not only ‘still existing’ in some form, but very much capable of interacting with the living!

You might say, “OK, that’s all very well – different cultures do things differently. That doesn’t mean we can’t define ‘too much time’ for a Western person in a Western context, right?”

Perhaps. But another researcher, Cooper (2013) has an interesting and relevant take on Western society’s views on grief: “Contemporary Western culture idealises people who are independent, happy and reliable, and it is surely no accident that these characteristics are also those that enable an individual to be economically productive in an advanced capitalist society. Persons whose grief is ‘disordered’ are a liability in our society, and this will create additional pressures to medicalise the symptoms of unusually intense or long-lasting grief” (p. 18).

In other words, stop being mopey and get back to work!
Even if you find Cooper’s position extreme, you have to admit it’s a bit off that you’re legally entitled to more days off work if you catch the flu than if your child dies.

There's also the thorny issue of gender to contend with. Researchers Martin & Doka (2011) point out a number of gender differences in mourning, and wonder if the reason women are highly over-represented in complicated grief statistics has more to do with their tendency to move through grief slower than any sort of ‘problem’ that needs solving with therapy or medication.

So taking all that into account … how in the world does one go about establishing if someone is experiencing this thing called ‘complicated grief’ or not?

Researcher Rosenblatt (2013), who has written extensively about complicated grief – both the fact of its existence and the hugely problematic process of defining it – offers his own set of diagnostic guidelines. He believes we should consider, in each and every case, whether a complicated grief diagnosis is likely to be

  1. Meaningful.
  2. Respectful.
  3. Appropriate.

Then apply it only if the answer is ‘yes’ to all three.

So if you’re reading this, and wondering if the label ‘complicated grief’ applies to you, I encourage you to ask yourself the same questions.
Regardless of who might have asked you why you’re “not over it yet”.
Regardless of where you are in your grief compared with those around you.
Regardless of what answers you get when you compare yourself to online checklists.

Do you feel like the label fits?
Do you feel OK using it?
Do you think it helps you make sense of what you’re experiencing?

There are plenty of questions around complicated grief – but really, those are the only questions that matter.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Boelen, P. A., van den Hout, M., van den Bout, J. (2013). Prolonged Grief Disorder: Cognitive-behavioral theory and therapy. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: scientific foundations for health care professionals (pp. 221-234). New York: Routledge.

Boerner, K., Mancini, A. D., & Bonanno, G. (2013). On the nature of complicated and uncomplicated patterns of grief. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 55-67). New York: Routledge.

Burke, L. A, & Neimeyer, R. A. (2013). Protective risk factors for complicated grief: a review of the empirical literature. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 145-161). New York: Routledge.

Cooper, R. (2013). Complicated grief: philosophical perspectives. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 3-26). New York: Routledge.

Golden, A. J. (2013). Autobiographical memory processes in complicated grief. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: scientific foundations for health care professionals (pp. 176-189). New York: Routledge.

Jordan A. H., & Litz, B. T. (2014). Prolonged Grief Disorder: Diagnostic, assessment, and treatment considerations. Professional Psychology: Research and Practice 45(3), 180-187. doi:10.1037/a0036836

Lundquist, K. F., & Nelsen, V. J. (1993). Personal reflections on death, grief and cultural diversity. In D. P. Irish, K. F. Lundquist, & V. J. Nelsen (Eds.), Ethnic variations in death, dying and grief: diversity in universality (pp. 183-197). Washington, D.C: Taylor & Francis.

Martin, T. L., & Doka, K. J. (2011). The influence of gender and socialisation on grieving styles. In R. A. Neimeyer, D. L. Harris, H. R. Winokuer, & G. F. Thornton (Eds.), Grief and bereavement in contemporary society: Bridging research and practice (pp. 69-77). New York: Routledge.

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C., Neimeyer, R. A., Bonanno, G., Block, S. D., Kissane, D., Boelen, P., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged Grief Disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121. doi: 10.1371/journal.pmed.1000121

Rando, T. A. (2013). On achieving clarity regarding complicated grief: Lessons from clinical practice. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: scientific foundations for health care professionals (pp. 40-54). New York: Routledge.

Rosenblatt, P. C. (1993). Cross-cultural variation in the experience, expression and understanding of grief. In D. P. Irish, K. F. Lundquist, & V. J. Nelsen (Eds.), Ethnic variations in death, dying and grief: Diversity in universality (pp. 52-73). Washington, D.C: Taylor & Francis.

Rosenblatt, P.C. (2013). The concept of complicated grief: Lessons from other cultures. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: scientific foundations for health care professionals (pp. 27-39). New York: Routledge.

Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. JAMA, 293(21), 2601-2608. doi:10.1001/jama.293.21.2601

Simon, N. M. (2015). Increasing Support for the Treatment of Complicated Grief in Adults of All Ages. JAMA, 313(21), 2172-2173. doi:10.1001/jama.2015.105

Solomon, C. G., & Shear, M. K. (2015). Complicated grief. The New England Journal of Medicine, 372(2), 153-160. Retrieved from http://ezproxy.aut.ac.nz/login?url=http://search.proquest.com/docview/1…

Stroebe, M, Schut H., & van den Bout, J. (2013). Complicated grief: Assessment of scientific knowledge and implications for research and practice. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: scientific foundations for health care professionals (pp. 295-211). New York: Routledge.

Wakefield, J. C. (2013). Is complicated/prolonged grief a disorder? Why the proposal to add a category of complicated grief to the DSM-5 is conceptually and empirically unsound. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 99-114). New York: Routledge.

Watkins, E. R., & Moulds, M. L. (2013). Repetitive thought: Rumination in complicated grief. In M. Stroebe, H. Schut, & J. van den Bout (Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 162-175). New York: Routledge.

Worden, J. W. (2009). Grief counseling and grief therapy: a handbook for the mental health practitioner (4th ed.). Springer Publishing Company, LLC.

advertisement