Understanding Complicated Grief: Definitions, Risk Factors, and Therapeutic Approaches
Summary
This podcast episode, hosted by Dr. Donal Snipes, provides a comprehensive overview of complicated grief, distinguishing it from normal grief and the newly introduced Prolonged Grief Disorder (PGD) in the DSM-5 TR. It emphasizes that loss extends far beyond the death of a person, encompassing a wide array of experiences such as psychosocial losses (divorce, illness, job, dreams), secondary losses (loss of income after a primary loss), anticipatory losses, moral injury, the loss of a 'moral self,' and even grieving never having had something like secure attachment. The core argument is that grief is highly individualized and multifaceted, impacting every dimension of a person's life.
A key distinction is drawn between complicated grief, which is used in a broader sense for various non-death-related losses (e.g., breakups, pet loss, within three months), and PGD, which is strictly applied to the death of a close person after a minimum of 12 months for adults (6 months for children). The episode critiques the DSM's relatively short diagnostic timelines for PGD compared to the traditional understanding of uncomplicated mourning as a 2-3 year process. A significant point highlighted is the substantial overlap between grief and trauma, with one study indicating that 53% of participants experienced significant trauma-related symptoms alongside grief, underscoring the feeling of unsafety and powerlessness inherent in both.
Practical insights and recommendations for counselors focus on tasks for successful grief resolution across physical, interpersonal, cognitive, environmental, and spiritual domains. Physically, this includes restoring circadian rhythms, healing the HPA axis, and maintaining healthy nutrition. Interpersonally, it involves navigating withdrawal, irritability, and self-absorption while eventually reintegrating. Cognitively, accepting phenomena like 'brain fog' and using aids is crucial. Environmentally, managing reminders of the loss is discussed, and spiritually, meaning-making is vital. The episode stresses the importance of validating the client's experience, recognizing that grief takes time, often continuing for a lifetime through major milestones, and that the first year is replete with triggers.
Broader implications include recognizing that grief profoundly impacts physical health (e.g., increased inflammation, compromised immune response), emotional well-being, cognitive function (stress-induced brain fog), interpersonal relationships, environmental interactions (e.g., needing to move), and spiritual beliefs. Counselors are encouraged to help clients address three fundamental questions: "What the heck just happened?", "How can I manage right now?", and "How do I go on now that I don't have this in my life?" The episode advocates for a holistic, empathetic approach that acknowledges the deep, pervasive, and long-lasting nature of loss and its unique expression in each individual's life.
Key Quotes
losses are really very diverse and it's important that we don't get stuck in only thinking about grief and bereavement in terms of death of a person
complicated grief has to do with grief that does not follow the quote normal course
prolonged grief disorder does overlap in many ways with the symptoms of complicated grief but again it has to do with the death of an individual
moral injury is the recognition of doing something that goes against your values goes against your morals
grieving the fact that it's unfair and you didn't get to have what you deserved is a process
there is a significant overlap between grief and Trauma in one study 53% of participants has significant elevations in trauma related symptoms
many times the therapeutic relationship is the first healthy relationship the person's actually had where they felt secure and they felt safe
grief takes time the whole first year is often one reminder of the loss after another
grief continues for a lifetime and through major life Milestones
when you're grieving you're under stress you're in this state of feeling unsafe and to a certain extent disempowered which means you're probably going to experience brain fog
Concepts
Themes
- The multifaceted nature of loss and grief
- Individualized grief experiences
- The diagnostic challenges and limitations of grief
- The profound impact of grief across all life dimensions
- The overlap between grief and trauma
- Strategies for grief resolution and accommodation
- The long-term, lifelong process of grief
Related to:
Psychology Insights
Clinical Recommendations
- Validate diverse loss experiences beyond death.
- Help clients identify and process secondary and tertiary losses.
- Address physical symptoms of grief, including circadian rhythm maintenance and HPA axis healing.
- Support clients in restoring routines and finding a 'new normal' after loss.
- Encourage acceptance of cognitive impacts like 'brain fog' and suggest coping strategies.
- Be aware of the long-term nature of grief and potential triggers during major life milestones.
- Recognize and address the significant overlap between grief and trauma symptoms.
- Guide clients in answering fundamental questions: 'What happened?', 'How do I manage now?', and 'How do I go on?'
Therapeutic Techniques
- Psychoeducation on the individualized, multi-dimensional, and long-term nature of grief.
- Cognitive reframing to address guilt, self-blame, and unrealistic expectations.
- Behavioral activation to restore routines, promote healthy nutrition, and manage energy.
- Mindfulness and acceptance strategies for emotional pain and cognitive challenges.
- Exploration of spiritual factors and meaning-making to find purpose after loss.
- Attachment-focused interventions for clients with insecure attachment or abandonment fears.
- Trauma-informed approaches when co-occurring trauma symptoms are present.
Paradoxical Mechanisms
- Grief can be more complicated when a relationship was bad, due to 'stuff left undone' or unsaid.
- Anticipatory grief, while a form of preparation, can still be intensely painful and complex.
- Discharging from a healthy therapeutic relationship can paradoxically trigger past abandonment grief.
- Retirement, a chosen life transition, can lead to significant identity disruption and grief over a lost persona.
Case Examples
- The podcaster's father dying at 50, leading to a feeling of being 'robbed'.
- Loss of income after a breadwinner's death, potentially forcing the sale of a house.
- Soldiers and law enforcement officers experiencing identity loss upon retirement.
- Children and foster parents grieving during foster care placement and reunification.
- A person becoming paralyzed and grieving the loss of a dream like running a marathon.
- The podcaster's experience of premature birth shattering the 'perfect birth scenario'.
- Parents grieving the loss of a dream for a child born with or developing a disability.
- Neighbors losing their house to fire, leading to a loss of property and sense of safety.
- Individuals grieving the 'loss of the moral self' after engaging in behaviors against their values.
- Clients grieving never having had secure attachment or 'Ward and June Cleaver' parents.
- Caregivers experiencing anticipatory loss for someone with a terminal illness or an aging parent.
- The podcaster's personal experience of grieving a dog's sudden illness and death.
- A friend retiring from the military, avoiding acknowledgment of the loss until the final day.
- Empty nest syndrome, exemplified by a parent struggling to shop for fewer people after children leave home.
- A stepfather mourning his first family, killed on Christmas Eve in the 1960s, for decades.
Research Mentioned
- Inventory of Complicated Grief (ICG)
- A study indicating 53% of participants experienced significant elevations in trauma-related symptoms alongside grief.
