When Grief is Complicated

A Model for Therapist to Understand, Identify, and Companion Grievers Lost in Wilderness of Complicated Grief

Center for Loss and Life Transition

Contents

Understanding the Origins of Complicated Grief

So, how is that some people end up in a wilderness of grief that is more rugged and perilous than the wildernesses of others? Why are some grief terrains more treacherous? In other words, how do some people's grief journeys get extra complicated?

In the Introduction we reviewed various definitions of complicated grief, historical and current. I contrasted the medical-model understanding of complicated grief as a disorder with my belief that complicated grief is a normal, human, soul-based response to naturally complex life and loss circumstances.

Here in Part One, we'll take a look at those naturally complex life and loss circumstances, which range from cultural contributors to circumstances of the death, the griever's relationship with the person who died, family systems influences, the funeral experience, and many others. These are the variables that — alone or, more often, in combination with one another — commonly result in complicated grief. They may form, if you will, the especially formidable topography of complicated grief.

Throughout this section, you will also find snippets of examples representing the voices of actual complicated grievers whom either I or caregivers who have participated in my trainings have companioned. In all cases, I have made an effort to minimize identifying details and protect confidentiality.

As we go over each of the influences on complicated grief, let's remember that "normal" grief and complicated grief are not truly distinct responses. Rather, we have agreed to understand complicated grief as normal grief — which by its very nature is always complicated — that has gotten extra complicated somehow. It's a matter of degree, feature prominence, functional impact, and, sometimes, duration.

In other words, there is not one backpack labeled "normal grief" and one labeled "complicated grief." We cannot separate them from one another nearly so neatly (though, as we discussed in the Introduction, I am well aware that the diagnosis "complicated grief" is the very thing that often allows grievers to receive the professional help they need and be reimbursed by their health insurance plans). There are simply grievers who, at some point in their journeys, are struggling to the degree that they would really benefit from the support of a trained grief companion. (I would further note that most grievers, at some point in their journeys, would likely be helped along by compassionate counseling, though it is often unnecessary for those with strong family and/or peer support.)

Complicated grief influences and risk factors

Please keep in mind that the grief influences and risk factors we are about to review together do not necessarily result in complicated grief. For example, multiple concurrent stressors is one of the influences that may contribute to complicated grief, but for various reasons, not everyone in seemingly high-stress circumstances will end up becoming lost or stuck in the wilderness of complicated grief.

Therefore, please do not think of the items in this section as a checklist or formula of any kind but instead merely a list of possible risk factors.

Also, it is possible that in your companioning practice you will end up working with grievers who do not appear to have any of the risk factors I list in this section yet who seem to be experiencing complicated grief. When this happens, do not fret! Human life, love, and grief are funny like that. There are simply not always clear causes or reasons for emotional and spiritual soul-based experiences. Love is mysterious, and so too is grief.

The bottom line is this: if someone in the wilderness of grief needs search and rescue, she needs search and rescue. Your job is to meet her where she is, provide a sacred and safe space, listen deeply with intent to understand, normalize without minimizing, and empathize without judgment. As each griever shares her story, at her own pace, you will be listening for these risk factors, of course, to aid in your understanding and to help you discern how best to help her get back on an effective path, but more important, you will be bearing witness to and honoring her unique love and grief. The complex mix of reasons why her unique love and grief are as they are is less important than accepting them at face value and accompanying her forward from there.

The below list of complicated grief influences and risk factors is numbered for ease of reference, but do not misconstrue that it is ranked. I have not presented the influences in any particular order. What's more, this list is not meant to be exhaustive, but it does represent the influences and risk factors I have seen most often in my many years as a grief counselor and educator. You may encounter others that are not included here. (If you do, I hope you will write to me about them at drwolfelt@centerforloss.com. I may have the opportunity to include your insights in a future article or book chapter.)

1. SOCIETAL CONTRIBUTORS

The remainder of the possible influences on complicated grief in Part One apply to the individual griever's unique loss circumstances, but this influence affects many if not most of us. At least here in America, we live in a culture in which many people do not "do" death and grief. And when death and grief are taboo, as they are here, our normal and necessary mourning is often stigmatized and suppressed. Our grief is, as Lutheran minister and professor of gerontology Dr. Kenneth Doka coined, "disenfranchised." In other words, our natural impulse to grieve and mourn is taken away from us.

How did this happen? First, we live in the world's first death-free generation. In centuries past, aging, illness, and death were much more a part of everyday life. Most people routinely suffered the (often premature) deaths of many loved ones. Today, many of us now live into our 40s or 50s before experiencing a close personal loss. Today two-thirds of all deaths in the U.S. each year happen to people who are 65 or older. While we certainly appreciate the medical advances that have helped lower the mortality rate and prolong lifespans, they have also distanced us from the normalcy of death and grief.

Second and relatedly, we have moved aging, illness, and death offstage and hidden them where we can't see them. Hospitals, nursing homes, and funeral homes were largely inventions of the 20 century. Before they became prevalent, families cared for their aged and ill loved ones at home. Death occurred in the home, and families prepared and sat vigil over the bodies of their dead loved ones at home. Young people learned the customs of grief and mourning — which included public expression of grief, use of ritual, and ample social support — at their parents' knees. Now, death and grief are considered unseemly, even morbid, and we have forgotten the extended, public, and ritualized norms that served us so well.

Third, we misunderstand the role of pain and suffering. Our Puritanical heritage has imbued in us the misconception that sorrow is self-indulgent, and modern medicine has taught us that pain is unnecessary. Whenever we experience pain, we simply need to take a pill or undergo some kind of treatment, and just like that, no more pain. Our Declaration of Independence even promises us the right to the pursuit of happiness. Grief is normal and necessary pain, but when pain is vilified, so is grief. And while this closeting of grief affects everyone, men have been especially subject to its edicts. Crying and talking openly about feelings and loss have long been considered unmanly. These and many other common misconceptions about grief and loss contribute to the incidence of complicated grief.

And fourth, our culture has increasingly moved toward the deritualization of loss and death. When everyday words and actions are inadequate, as is the case when a loved one dies, ceremony is essential to helping us embark on a solid path in the wilderness — one that leads to healing. But we are abandoning our religious and social communities that uphold ritual, our funerals are getting shorter, and with the trend toward memorial services, we are separated from both the time of the death and the body of the person who died. We're having parties instead of gatherings that help us embrace and express our necessary sadness and support one another. And it's becoming more and more common for ceremony to be skipped altogether.

When you add all of these cultural influences up, what you have is an environment in which grief is likely to be denied, suppressed, and/or unsupported. In such circumstances, it's not a stretch to see that normal grief can easily become complicated grief — even in cases in which none of the other influences in this section definitively apply.

In recent years, I have been heartened to see more open public conversations about the normalcy of grief. The popularity of the recent book by Facebook Chief Operating Officer Sheryl Sandberg about the unexpected death of her husband, Option B, is just one example of this cultural shift. I am hopeful that one day in the not-too-distant future the principles of grief will be reviewed and openly discussed in schools, and that future generations will grow up knowing that grief and mourning are as normal and necessary as love, healthy relationships, and good interpersonal skills. I also hope death and funerals return to being more normalized, essential, personal, and meaningful rites of passage.

In the meantime, though, be on the lookout for insidious societal contributors to complicated grief as you companion struggling grievers. When the time is right, many complicated grievers need help seeing the cultural influences on their grief experiences as well as permission to forge for themselves a new, better path.

2. CIRCUMSTANCES OF THE DEATH

When we love someone and they die, we suffer grief. As I have noted, grief is always challenging and complicated. But certain loss circumstances tend to be exceptionally and understandably challenging and complicated, making the experience of complicated grief more likely.

Sudden, unexpected death

Even when someone we love is terminally ill and death is imminent, I have observed that we are never really ready for the death. The transition from "alive" to "dead" always comes as a shock. There is simply no preparing for lifelessness in a body that had animated a soul we cared deeply about. But when a death is sudden and unexpected, feelings of shock and unreality are compounded. Accidental deaths fall into this category, as do military deaths, murders, suicides, and deaths by sudden illness.

In such cases, a heightened sense of unreality is common, as is a focus on the particulars and day of the death. For these and all the death circumstances we will be discussing in the following paragraphs, an extended period of shock and numbness is common.

Sometimes insensitive or inappropriate death notification also plays a role in the grief that follows sudden, unexpected deaths. Medical and law enforcement staff, for example, are not always empathetic communicators. In addition, the immediacy and informality of social media and texting sometimes result in next of kin first hearing about a death in unsuitable ways. "I just heard your son was the person in that fatal car accident! I'm so sorry!" someone might post on Facebook — before the parent even knew there had been a car accident.

It's also normal for grievers to be traumatized by certain death circumstances, especially those that in addition to being sudden and unexpected are also violent. In an effort to understand and come to terms with what has happened, the human mind tends to replay or reimagine the event of the violent death over and over. In this way, complicated grief and post-traumatic stress may overlap. People affected by traumatic deaths have special needs, and we will discuss how to help them meet these needs in Part Three. And always remember that each griever will teach you whether or not he considers the death he is mourning "traumatic." In the ways that matter most, this is a subjective categorization. What truly counts is the griever's experience and inner reality.

Before-time death

The death of a young person is always hard to accept. Especially now, in the age of modern medicine, we can be reasonably confident that the young people we love will have the opportunity to grow to adulthood. But though the odds are in our favor, there are no such guarantees, of course. Children still die of disease, accidents, and homicide. Some tragically die by suicide.

Keep in mind that our sense that a death has occurred before its time extends to young adults and even middle-aged friends and family members. As longevity increases, we simply expect people to live longer. Today, we take it for granted that most people will live into their 80s or 90s. So when a 64-year-old dies, for example, we might well consider that this person died "before his time" — especially if we ourselves are middle-aged or older than the person who died.

In addition to a prolonged period of shock and numbness, people grieving an early death may be more likely to experience more pronounced feelings of guilt and explosive emotions, which are a form of protest.

I also consider it a before-time death when a parent of a child dies. From the child's point of view, the parent has broken a contract of sorts. By a young age, children tacitly understand that parents or parent figures are supposed to take care of them at least until they grow to adulthood. When this promise is broken by premature death, the child naturally struggles to come to terms with the foundational collapse in his life. For many young people it can seem like the laws of physics have been violated. It feels disorienting, scary, frustrating, and unjust.

Out-of-order death

When someone dies whom we believe should have outlived us, we sense that the death is out of order. It's as if a rule of nature has been broken. Whenever a child dies before a parent or grandparent, for example, this is the case — even when the child is an adult.

As with a before-time death, in addition to an extended period of shock and numbness, people grieving an out-of-order death may experience more pronounced feelings of guilt and explosive emotions. Guilt often arises when people perceive they have unfairly outlived or failed to protect a younger person. Anger and other explosive emotions protest the injustice of a life cut short.

Means of death

Certain types of deaths make them naturally more challenging for grievers to acknowledge and encounter the pain. These include deaths by suicide, homicide, and senseless accidents, of course, but also military deaths, terrorism deaths, deaths by natural disasters, and others. We find them incomprehensible.

In general, the more violent and extreme the circumstances of the death, the harder it is for grievers to move beyond shock and numbness, acknowledge the reality of the death, and embrace the pain of the loss. The same can be said of random deaths and deaths that are perceived as having been preventable. Any social stigmas commonly associated with some of these types of death, such as suicide and deaths caused by what may be perceived as bad judgment or foolhardy risk-taking, further compound the complications.

Because they are intentional and premature, among other reasons, suicide and homicide are especially naturally complicating death circumstances, each with their own unique and profound challenges.

The terrain of suicide grief is always harrowing. It is unfathomable that someone you love, cherish, and maybe depend on would physically and permanently remove herself from this world and from you on purpose. This breaks the contract of love. This flouts the sanctity of life. Prolonged shock and numbness are common, of course, as is the need to try to understand the ununderstandable. It's normal to search for "why" and new meaning in life, but when meaning rules have been broken by suicide, the search is often both all-consuming and endless. Self-blame, blame directed at others (including the person who died), and anger are typical though not always present. Meanwhile, autopsies, police investigations, media coverage, and life insurance issues create more strife and pain and may cause secondary victimization. And the means of death is often a naturally traumatic focus for survivors, especially those who witnessed the death or discovered the body of the person who died.