When is Grief Complicated?
Grief - Tree through rain by Seyed Mostafa Zamani @ FlickrPhoto Credit: Seyed Mostafa Zamani

Grief is the expected and arguably necessary human response to loss.  Grieving has a purpose: it is the process by which an individual confronts the incredible range of emotions that can take hold after loss, from anger to disbelief to depression and back again. Nearly everyone, at some point, will live through some kind of loss, be it losing employment or one’s home, living with a major illness or injury, or the death of a loved one.

Human behavior is both surprisingly variable and universal. That grief occurs after loss is self-evident; what is harder to explain is the incredible variation in the expression of grief between individuals. In some cultures, for example, it’s appropriate to display one’s grief publicly, while in others, grief is a private process.

In fact, one study suggests that private rituals may help people cope with grief better than public ones. Researchers from Harvard Business School found that it was no single ritual that helped people move on more quickly, but the fact that they engaged in a personal ritual at all. The key element, they argue, is the feeling of control that is restored (Norton and Gino, 2014).

In their classic book On Grief and Grieving, David Kessler and Elizabeth Kubler-Ross point out five common stages of grief:

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

They emphasize the individuality of the grief process, using these stages as guideposts for understanding the feelings that emerge. They also highlight the importance of allowing oneself to feel uncomfortable emotions, such as anger. Kubler-Ross and Kessler argue that our culture tends to resist the grief process. Instead, we prize moving on and getting back to normal. However, suppressing, or repressing, the normal human response can lead to dysfunctional grieving and delay of resolution.

Sometimes, grief progresses, or is so extreme, as to overwhelm an individual’s coping mechanisms. When this occurs, we call it complicated grief or persistent complex bereavement disorder. Anyone experiencing complicated grief is unlikely to resume a normal life until some kind of treatment intervention takes place. So when is grief complicated? Perhaps a more apt question is when is grief not complicated?

Normally, grief does not require treatment. As Kessler and Kubler-Ross posit, encountering the five stages of grief is not always a linear progression. Emotions can emerge unexpectedly; some stages persist longer than others. There is no predictable trajectory. All of that can be normal. And yet our culture may be subliminally supporting the repression of these difficult emotions, and that can lead to more serious problems.

The DSM V states that grief is complicated when someone becomes intensely focused on the loss, is unable to accept the loss, may feel bitter or angry, feels detached from others, and cannot fathom a life of meaning without the person who is gone, among other diagnostic criteria. The symptoms last a year or more and cause a marked inability to function in caring for oneself or dependents, in social settings, or at work. At this point, intervention with an evidenced-based treatment model, such as cognitive behavioral therapy or pharmacotherapy may be indicated. If you are experiencing this level of complicated grief, you should strongly consider seeking professional mental health services.

From a clinical perspective, any extreme psychological behavior is a ‘disorder’ when the symptoms prevent the individual from carrying out his or her role and responsibilities in life successfully, again pointing to the emphasis we place in our culture on productivity and functioning. But if we try to preempt grief, we lose a valuable opportunity to examine the psychological underpinnings of our actions, behaviors, and relationships to others.

Is there a way to prevent complicated grief? Despite our culture’s preference for forging on in the face loss, allowing our emotions to emerge and expressing them to trusted others is an essential task. In short, grief cannot be skipped. As the study above suggests, finding personal rituals may promote healthy grieving and prevent repressing the experience, which can lead to more disordered grieving later on. Grief need not be an illness. We only make it so when we disconnect ourselves from the experience.

Resources to Help with Grief

Local hospices, funeral homes, hospitals, and places of worship often have grief support resources or can refer you to a support group.

The Dougy Center includes over 500 centers that provide grief support and services.
http://www.dougy.org/grief-support-programs/

THe Hospice Foundation of America lists resources for those coping with major illness
http://hospicefoundation.org/

GriefNet.org is an Internet community of persons dealing with grief, death, and major loss.

Sources

Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Arlington, VA: American Psychiatric Association, 2013.

Kubler-Ross, M.D., E. and Kessler, D. On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. New York, NY: Scribner, 2005.

Norton, M. I., and Gino, F. Rituals Alleviate Grieving for Loved Ones, Lovers, and Lotteries. Journal of Experimental Psychology, 143, 266-72. 2014.

Sadock, M.D., B.J, and Sadock, M.D., V.A. Synopsis of Psychiatry, tenth edition. Philadelphia, PA: Lippincott Williams & Williams, 2007.

About this Contributor: Cassandra received her Master’s in Nursing from The University of Southern Maine and her undergraduate degree from Brown University. She is certified as a Family Psychiatric Mental Health Nurse Practitioner and works in community mental health in Portland, Maine. She enjoys working with clients from a holistic perspective, helping others gain insight into the connection between physical and mental health. Cassandra was the editor of Yoga Wisdom and also writes about mental health issues; an article she co-authored, “The Will to Thrive”, was published in Issues in Mental Health Nursing. She enjoys living in Portland and its many opportunities to spend time outside.


  1. Are you asking yourself “what is complicated grief?” “Grief” is a simple word for a complex experience and in that sense all grief is complicated. However we use the term complicated in the medical sense, meaning that something is interfering with coping with a loss. You can think of losing a loved one as somewhat like a physical injury and psychological issues that interfere with grief as like an infection that complicates wound healing. This is what we mean by complicated grief.

  2. This is an apt comparison. The healing process is an organic one – and remarkably unique to each person. Thank you for sharing your insights!

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