Grief is not an illness and it is important not to "pathologize" it as such. As the report of the Center for the Advancement of Health states, "the majority of the population appears to cope effectively with bereavement-related distress, and most people do not experience problematic grief or adverse bereavement-related health effects" (Genevro, Marshall, &
Miller, 2003, p. 10). However, there are times when an individual may become "stuck"
in the grief process, for example when the loss is a traumatic one (e.g. homicide, death of a child, multiple losses due to AIDS). Over the years, a number of theorists and researchers have attempted to describe the phenomenon of complicated grief and there has been much confusion over the proper term to use (e.g. complicated grief, pathological grief, or complicated mourning) (Middleton, Moylan, Raphael, Burnett, & Martinek, 1993; Goldblum & Erickson, 1999) as well as how to assess and classify it (Genevro, Marshall, & Miller, 2003). There has been much overlapping in the identification and classification of abnormal or pathological grief reactions (Lindemann, 1944; Lazare, 1979; Parkes, 1965; Parkes & Weiss, 1983; Bowlby, 1980; Worden, 1991). According to Middleton et al. (1993):
Pathological grief is not represented in official diagnostic manuals. Nor is it an established "clinical entity"... [and] there is considerable overlap with other, more operationally defined syndromes, such as depression, anxiety, or post-traumatic stress disorder. (p. 59)
I prefer to use the term "complicated grief' and I will use this term throughout when referring to this phenomenon. A widely cited definition of complicated grief is by Horowitz, Wilner, Marmar, and Krupnick (1980) who defmed it as:
the intensification of grief to the level where the person is overwhelmed, resorts to maladaptive behavior, or remains interminably in the state of grief without progressIOn of the mourrung process towards completion...[It] involves processes that do not move progressively toward assimilation or accommodation but, instead, lead to stereotyped repetitions or extensive interruptions of healing. (p. 1157)
On the other hand, Goldblum and Erickson (1999) simply defined complicated grief as
"an atypical intensity or duration of grief symptoms that leads to a level of functional impairment in critical areas of work and relationships" (p. 2). Worden's (1991) perspective of complicated grief is one that is commonly referred to by researchers and practitioners in the bereavement field today. He identified four types of complicated grief reactions: chronic grief, delayed grief, exaggerated grief, and masked grief. Chronic grief is when the grief is excessive in duration and does not come to a satisfactory conclusion. Individuals experiencing this type of reaction are usually aware that they are not moving through the grief process. Delayed grief is when the individual has an emotional reaction at the time of the loss, but it is insufficient. The individual may feel so overwhelmed at the time of the loss, that it causes their grief to be delayed. When a later loss occurs, the grief is triggered and the individual's response will be more intense and exaggerated compared to the past loss. Exaggerated grief has to do with excessive and disabling reactions to loss and psychiatric disorders develop following the loss such as clinical depression, anxiety, alcoholism, and post-traumatic stress disorder. Usually,
the individual is aware that his/her response is abnormal and will seek help. In masked grief, the individual will experience symptoms and behaviors that will cause them difficulty but they are not aware that they are related to the loss. In masked grief, the grief shows up masked as a physical symptom or as some type of aberrant or maladaptive behavior. The individual may experience physical symptoms that were similar to those of the deceased before he/she died (Worden, 1991).
Symptoms of Complicated Grief
Bereavement interventions are usually not needed for individuals experiencing normal grief but' they may be helpful for "a small, though significant, percentage of the population [who] experiences complicated grief' (Genevro, Marshall & Miller, 2003, p.
10). Robert Neimeyer (1998), a clinical psychologist and renowned bereavement scholar in the United States, indicated that professional counseling may be required for bereaved individuals who experience any of the following conditions on a continual basis:
substantial guilt, suicidal thoughts, extreme hopelessness, prolonged agitation or depression, physical symptoms (e.g., stabbing chest pain or extreme weight loss), uncontrolled rage, persistent impairment in everyday functioning (e.g. job, daily living tasks), and substance abuse.
The following are symptoms of complicated grief, adapted from Lindemann (1944), Lazare (1979) and Worden (1991):
• The person develops physical symptoms similar to those of the deceased before death.
• Panic attacks, choking sensations, and shortness of breath.
• Searching behavior that continues over time.
• Extreme anger directed toward those involved at the time of death (e.g. doctor, nurse).
• Lack of emotion.
• Agitated depression, feelings of worthlessness, and persistent guilt.
• A feeling that the death occurred yesterday, even though it was months or years ago.
• An inability to talk about the deceased without experiencing fresh and intense grief even when the death occurred over a year ago.
• Unaccountable sadness occurring at a certain time each year.
• A minor event triggers a major grief reaction.
• False euphoria subsequent to the death.
• Radical changes in lifestyle.
• Acting in a way that can be detrimental to one's social and economic existence (e.g. making foolish economic decisions, giving away things).
• Unable to move the possessions of the deceased after a reasonable time has passed and preserving the environment exactly as it was at the time of death.
• Refusing to participate in mourning rituals such as attending the funeral or visiting the grave.
• A compulsion to imitate the dead person's behavior.
• Phobias that one will develop the illness that took the deceased.
• Changes in relationships with friends and family.
• Excluding friends, family, or activities connected with the deceased.
Causes of Complicated Grief
Neimeyer (1998) identified factors that could result in complicated grieving. They are:
characteristics of the bereaved individual (e.g. use of maladaptive coping strategies such as alcohol and drug use); level of support available to the bereaved individual; and
"bereavement overload" (when the individual is confronted by multiple deaths in a certain time period such as individuals who have lost many of their loved ones to AIDS).
Neimeyer suggested that the most significant risk factor for complicated grieving is whether the individual had difficulty coping in the past with similar major losses.
Table 3.3 summarizes risk factors for complicated grief, adapted from the work of several authors (Lazare, 1979; Parkes & Weiss, 1983; Worden, 1991; Gamino, Sewell,&
Easterling, 2000; Parkes, 2002). I have adopted Worden's classification system. He categorized risk factors for complicated grief as: relational factors (aspects associated with the relationship with the deceased); circumstantial factors (circumstances
surrounding the loss); historical factors (prior losses); and personality factors (aspects of the person's character).
Table 3.3 Risk factors for complicated grief
Relational factors
Ambivalent toward the deceased Highly dependent on the deceased
The deceased represents an extension of oneself Lost opportunities to have a certain type of relationship Circumstantial factors
Loss is uncertain (e.g. when the body is not found) Sudden or unexpected losses
Traumatic death (violent or horrific losses) Multiple losses
Losses for which the person feels responsible Losses where others are to blame
Disenfranchised losses (i.e. losses that are not acknowledged by society) Historical factors
Previous history of complicated grief reactions Early parental loss
Poor or insecure attachments to parents during childhood History of mental health treatment
Personality factors
Unable to tolerate emotional distress Unable to tolerate feeling helpless
Feeling that one needs to be "strong" for the family Social factors
The loss is "unspeakable" (e.g. suicide, AIDS) The loss is negated (e.g. miscarriage)
Absence of social support Social isolation