Grief: It’s complicated (10% of the time)

by Susan Delaney

Eileen’s husband, John, died suddenly in a car crash. Eileen and John lived a quiet, ordered life. They had a very close relationship and rarely socialised with other people. Nine months on, Eileen has not returned to work and no longer sings in the church choir which she used to enjoy. She spends a lot of time in bed sifting through photographs of John and wishing she had asked John to take the bus instead of driving on the day of the accident. Eileen tells family members that John was her soul mate, that she cannot face life without him and hopes she will die soon so they can be reunited. Sheryl’s husband Dave died unexpectedly on a Friday evening. Ten days later Sheryl returned to work part time, having received advice to get back to a daily routine as soon as possible.She posted the following message on Facebook: “…as heartbroken as I am today, I am equally grateful. Even in these last few days of completely unexpected hell — the darkest and saddest moments of my life — I know how lucky I have been. Things will never be the same – but the world is better for the years my beloved husband lived”. Eileen is a composite of clients who present with bereavement issues and Sheryl is, of course, Sheryl Sandberg COO of Facebook. Two women who had deep and satisfying relationships with their partners, and yet very different grief reactions.

So, whose grief response is normal? What does normal grief look like? What does disabling grief look like? When does grief become a diagnosable disorder?

Most bereaved people’s grief experience will fall somewhere between Eileen’s and Sheryl’s and most bereaved people integrate their grief without any professional input. This means that, while they will continue to miss and think about the person who died, they will no longer be overwhelmed by their grief and will be able to re-engage with their life and return to a similar (or close to) level of pre-bereavement functioning.

Whether grief should ever be considered diagnosable is a hotly debated issue, many people argue that grief should never be pathologised and that grieving simply takes as long as it takes. This view is not borne out by research and robust findings suggest that 10% of bereaved people will develop complicated grief (CG) that requires a targeted treatment to address the complications and facilitate the natural healing process. Given that almost 30,000 people die in Ireland every year, each leaving behind several bereaved people, this statistic suggests that, conservatively, up to 15,000 Irish people will develop CG annually. Our task as practitioners is to determine at what point a person’s grief reaction is outside of cultural norms and impacting negatively on his or her level of functioning. We need to do this in a standardised way; otherwise we run the risk of relying too heavily on our personal experience of grief and working out of our own death anxiety rather than an evidence-base.

CG can be diagnosed using standardised inventories coupled with a thorough grief history and assessment. DSM-5 sets 12-months post-bereavement as the minimum time frame for diagnosis, however robust research by Holly Prigerson (1995) clearly indicates that it may be diagnosed as early as six months post-bereavement. This does not mean people are over their grief in any way, but that resilience has begun to operate and they are showing signs of adjusting to a life without their loved one. Many practitioners find this six- month marker counter-intuitive and believe bereaved people need ‘at least a year’ to begin making sense of their loss. In fact there is little evidence to support this position and we risk leaving bereaved people to struggle or feel they are not trying hard enough if we don’t consider the possibility that their grief has been derailed and some psychological intervention is needed to get the grief back on track.

Popular notions about how we grieve, including the idea of fixed stages of grief and the importance of closure have, for the most part, now been discarded as research evidence has failed to support their validity. Neuro- imaging findings have re-awakened an interest in human attachment, and researchers such as Mikulincer (2009) have refined the early work undertaken by John Bowlby (1980) to explain the central role of attachment in our lives and in our losses. All human beings are hard-wired to attach to significant people in their lives; people who provide a safe haven when we need comfort and provide a secure base that gives us the confidence to go out and explore the world. Grief is a natural consequence of forming these emotional bonds to others; we grieve when we lose someone who is important to us. When we experience the loss of a significant person in our lives, our physical and emotional well-being is disrupted; we resist accepting the finality of the loss and struggle to make sense of what has happened and how to live without that person, but our natural healing process helps us through. We find a way to make sense of the loss and adjust to a life without that person.

For people with CG this adjustment and meaning-making does not occur. Instead of the grief integrating, the process is derailed, sending it into a repetitive loop with intense yearning, avoidance and preoccupation with the death predominating the emotional and cognitive landscape. The bereaved person has little enthusiasm for life and cannot imagine a time that they will ever feel joy or passion in their life again. The metaphor of a train can be a useful way to explain complicated grief; if grief is imagined as a train journey, then each bereaved person finds their own route, stopping at different stations for different lengths of time and arriving at their own destination. When someone has CG it is as though obstacles (complications) have caused the train to derail and no progress can be made until the debris is removed from the track.

Bowlby recognised that a successful period of mourning consisted of acknowledging the finality of the loss and its consequences, revising the internal representation of the person who died and redefining life goals. This is echoed in William Worden’s (2008) more contemporary work on grief tasks. Research by George Bonanno (2002) highlighted the role of resilience and added significantly to our understanding of grief trajectories by evidencing the fact that failure to integrate grief was the exception rather than the rule.

The acceptance of CG as a disorder has led to the development of several innovative treatment protocols, most notably that developed by Dr. Kathy Shear in Columbia University (2006) known as Complicated Grief Therapy (CGT). CGT has been shown to significantly reduce symptoms of grief and improve level of functioning when compared to traditional non-directive therapy. The CGT protocol uses strategies and techniques to facilitate the three main processes that reshape grief; acknowledging the death and its consequences, revising the mental representation of the person who has died and redefining life goals in light of the life changing events. CGT also focuses on finding and resolving the grief complications; the superimposed problems that are derailing the healing process. These are often counterfactual beliefs related to the circumstances, consequences or context of the death. Sessions are structured and follow a similar format, beginning with a review, moving on to particular exercises focusing on the death and consequences, then shifting to activities of restoration and ending with plans for the following week. Clients are active collaborators in the process and are asked to engage in daily activities of grief monitoring, goals work and self-compassion. Both imaginal and situational activities are utilised, as well as structured memory work, photographs and an imaginal conversation with the deceased. Progress is monitored regularly and feedback is used to structure the protocol to the client’s needs and to refine the understanding of why the grief process became stuck. As the instinctual healing process is activated, the working model updates and the grief begins to integrate.

Of course, protocols and techniques alone don’t heal people, and effective treatment will always be predicated on the ability to form a strong therapeutic alliance and tailor treatment interventions to fit with the client’s experience and interpretation of the problem. Duncan Hubble and his colleagues provide an excellent overview of what makes for effective therapy in their book, The heart and soul of change. They break down the effectiveness variance into: 40% due to client factors, 30% due to the therapeutic relationship, 15% accounted for by the instillation of hope and expectation, and 15% accounted for by the techniques utilised. To ensure that bereavement therapy is both effective and self-sustaining, David Morawetz (2007) recommends that therapists focus on using the relationship to empower the client both in and outside of sessions, generate realistic hope without minimising the difficulties, and utilise relevant and proven techniques to ensure that the therapy is effective and self-sustaining. One of the best predictors of negative outcome in therapy is a lack of focus and structure, and when working with CG it becomes even more important to have a clear hypothesis rooted in bereavement theory and a therapeutic approach with an evidence base behind it. Shear’s protocol meets the criteria suggested by Morawetz and this author’s experience with using CGT over the past four years has been very positive. Birgit Wagner’s (2006) internet approach is also reporting promising outcomes, and no doubt further treatment protocols will follow.

C.S. Lewis (1961) reminds us in A grief observed, “Bereavement is a universal part of the experience of love…it is not the interruption of the dance, but the next figure of the dance” (29). People with CG erroneously believe that they need to hold tightly to their grief as a way of staying connected to their loved one, they fear forgetting and can become locked in a vicious cycle of either feeling bad or feeling bad if they start feeling better. The truth is that we are forever connected in a deep way to those we love, but it is possible to remember them with love rather than with pain, and it is possible to reconnect with life and find meaning and joy after bereavement.

People with CG tend to present at GPs’ offices and bereavement support services, very often at the request of family members who are at a loss as to how to help them and find their inability to accept the death and ‘get on’ with things both frustrating and incomprehensible. Truly, no one would choose to feel the way people feel when their grief is stuck, and frequently the bereaved person is just as frustrated as everyone else.

CG remains a poorly understood concept associated with significant distress and impairment combined with negative health consequences. Ireland has taken a lead in providing evidence-based treatment for people presenting with complicated grief and is one of three sites in Europe engaged in CG research, training and service provision. Over 100 practitioners drawn from psychiatry, psychology and psychotherapy disciplines have now been trained in CGT in Ireland over the past four years, with most of the 26 counties now represented.

Wherever we position ourselves on the ‘pathologisation of grief’ debate, it is worth remembering that diagnostic categories ultimately serve only one purpose and that is to reduce the suffering, incapacity and misery of the people who seek our help. With more awareness and effective intervention strategies we can now offer hope to people presenting with complicated grief.

Dr. Susan Delaney is a Clinical Psychologist and heads up the Complicated Grief programme at the Irish Hospice Foundation. She teaches bereavement counselling skills on the in-house Master’s programme and is a member of the International Train-the-Trainers group with Columbia University in New York.

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Bowlby, J. (1980). Attachment and loss: Volume 111: Loss, sadness and depression. The International Psycho-analytical Library, 109, 1-462. London: The Hogworth Press.

Gundel, M.D. (2003). Functional neuroanatomy of grief: An fMRI study. American Journal of Psychiatry, 160(11), 1946-1953.

Hubble, M., Duncan, B., & Miller, S. (1999). The Heart and Soul of Change: What Works in Therapy. Washington DC: American Psychological Association.

Lewis, C.S. (1961). A Grief Observed, London: Faber.

Mikulincer, M. (2009). What’s inside the mind of securely and insecurely attached people? Journal of Personality & Social Psychology, 97(4), 615-633.

Morawetz, D. (2007). What works in grief counselling? US evidence and Australian experience. Grief Matters, 10(3), 56-59.

Prigerson, H.G., Maciejewski, P.K., & Reynolds, C.F. (1995). Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65-79.

Shear, M.K., & Delaney, S. (2015). On bereavement and grief: A therapeutic approach to healing. In K.E. Cherry (Ed). Traumatic Stress and Long-Term Recovery, New York: Springer.

Shear, M.K. (2006). The treatment of complicated grief. Grief Matters: The Australian Journal of Grief and Bereavement, 9(2), 39-42. [This link leads to a 10 minute interview with Dr Kathy Shear as she discusses complicated grief: watch?v=aAEfYSOS8W8].

Stroebe, M., Schut, H., & van den Bout, J. (Eds.) (2013). Complicated Grief, Hove: Routledge.

Wagner, B., Knaevelsrud, C., & Maercker, A. (2006). Internet-based cognitive-behavioral therapy for complicated grief: A randomized controlled trial. Death Studies, 30, 429- 453.

Worden, J.W. (2008). Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner (4th ed.). New York: Springer.