Complicated Grief: How It’s Different

Here’s what to do when the intense pain lingers.

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Losing someone close to us is as painful as it gets. But if the sharp pain fails to lift, it might be what’s called “complicated grief.” Modern Loss spoke with Dr. Katherine Shear, program director at Columbia University’s Center for Complicated Grief, about warning signs, how complicated grief differs from depression, and (the good news!) what can be done to help.  

How is complicated grief different from “general” grief, which seems so complicated in and of itself?

Navigating a world that is profoundly and irrevocably different is challenging.  However, most of the time we figure out how to live our lives without our loved one in a way that makes it possible to experience joy and satisfaction and to find purpose and meaning. When that happens our grief is not completed or gone, but is reshaped — transformed and integrated so it is a part of the background of our lives.

Grief complications are certain kinds of thoughts, feelings and behaviors that derail this natural healing process. People with complicated grief often feel “stuck.” Their pain stays almost as intense as it was in the beginning.

People with CG don’t know what is wrong. They assume their lives have been irreparably damaged by their loss and cannot imagine how they can ever feel better. Grief dominates their lives with no respite in sight. Relationships with family and friends flounder. Life seems purposeless, and health is jeopardized.

Why haven’t most people heard of this before? 

For many years, the mental health community treated grief as if though it were depression, and there still some confusion about this in the mental health field. Research identifying complicated grief began in the 1990s, but this condition was included for the first time in the DSM5 [the American Psychiatric Association’s guide to mental disorders] in May of this year.

How is this different than depression? 

[The] main symptoms of complicated grief are yearning, longing and frequent thoughts of the person who died. They typically retain a strong interest in a deceased loved one and experience positive emotions when they think about that person; all of their negative emotions are sharply focused on the circumstances or consequences of the death.

People with complicated grief often also have depression. This means that in real life this is not an “either/or” question. I recently wrote an article explaining more about this relationship.

What are the signs?

We think of CG as having two parts. One is prolonged acute grief. The other is complicating thoughts, feelings and behaviors. Grief complications are typically:

  • recurrent troubling thoughts about the death (eg: thinking over and over that someone could have done something different that would have prevented this death)
  • behaviors to try to block out the painful reality (leaving a room or possessions untouched, spending a lot of time day dreaming about being with the deceased person or protect oneself from being reminded of them, trying to avoid people places or things that they used to do with the deceased person)
  • feelings like guilt or anger that are difficult to control

Are some people more predisposed to experience complicated grief than others?

We don’t have good research data about this yet, but we have some ideas and hints about which types of people are probably at a heightened risk:

  • women appear to be more susceptible than men
  • people who are vulnerable to mood or anxiety disorders
  • those who had a difficult relationship with their parents growing up
  • losing a loved one in a sudden, violent way

Most people who have CG have lost someone very important with whom they have had a positive, rewarding relationship. Most commonly it’s a child or a romantic partner. However, only 7-10% of bereaved people have CG so most people who lose a very close, very rewarding relationship do not develop CG.

What advice do you have for people trying to support someone grappling with complicated grief? 

  • Educate yourself about CG and understand that people who have it are not “wallowing in grief” but are struggling with symptoms that they can’t seem to control. People with CG feel as if the loss just happened.
  • Understand that people with CG may be especially sensitive to feeling abandoned. They may be less available than usual. They feel like they’re not the same as before their loved one died, and in some ways this is very true.
  • Many times of year may be especially difficult for a person. For example, the day of the death, the deceased person’s birthday and family holidays, and the end-of-year holiday season, to name a few. Reach out to the person at those times. When you do, try to spend time with the person.
  • Talk about the person who died. People with CG appreciate that. Let the person know that you want to hear how they are really feeling. It’s ok to talk about feeling sad and hurt. You don’t have to fix that. Just listen and let her talk or cry.
  • Don’t be afraid of moments of silence; they do not always need to be filled.
  • Hold your friend’s hand or give them a hug — physical gestures are powerful and can sometimes convey what our words cannot.

What’s the treatment for this? Is it a targeted, short-term treatment or an ongoing long-term one?

We developed a 16-session (four-month) targeted psychotherapy called complicated grief treatment (CGT). We work with people to re-envision their own lives and to think about their long-term aspirational goals. We help them reconnect with other people in their lives and to deepen the sense of connection with the deceased person and increase their confidence in the durability of that connection. To achieve these goals the therapist asks people to revisit with the time of the death in imagination and reflect on that experience with the help of the therapist. We also ask that they start to revisit activities or situations they have been avoiding.

Besides CGT, what resources are available to people dealing with complicated grief? 

I am writing a treatment manual that will be published by Guilford Press within the next year. The mission of the Center for Complicated Grief is to help people with CG find effective resources through public awareness and through training professionals.

What would you say to those who feel isolated in their situation right now?

Unless others have also experienced a very difficult loss they may not understand what you’re going through or know how to help you. This can be frustrating and hurtful to someone who is grieving, but there are things you can do. One is to practice self-compassion, as best you can.  This means being kind and supportive to yourself and not harsh or self-critical. Try to remember everyone suffers and allow yourself to feel your pain without letting it take over your life.

 Dr. Katherine Shear is Director of the Center for Complicated Grief at the Columbia University School of Social Work. Her work with complicated grief began in the mid-1990s, when she and colleagues identified the syndrome.

*Interview edited for length and clarity

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