PROMOTING EDUCATION & AWARENESS OF LONG-TERM GRIEF COMPLICATIONS
Mourning for loved ones following their death is a completely natural part of life and deserves to be properly embraced. It's an important and special connection that we have with our loved ones and reflects often very deep and profound sentiments regarding the relationship that we had with them in life and continue to have with them after their death.
Grieving is not only a necessary process but is often a challenging and highly complex one. Essentially people mourn in different ways, this depends not just on the individual but on the death itself and its circumstances but a wide variety of other factors including society and culture. The type and extent of the mourning 'process' varies extensively between individuals who are affected by various aspects of bereavement and loss.
People develop different coping mechanisms that help them to negotiate their way through their bereavement and to deal constructively with feelings and emotions regarding the nature of their loss. Although it can be emotionally painful for most people this is often a relatively manageable life event that eventually finds some manner of reconciliation in the short to medium term.
For people suffering with Complicated Grief/Persistent Complex Bereavement Disorder, however, this reconciliation is a great deal harder to find.
In recognition that this can be confusing for somebody coming to this with no previous knowledge and/or experience of it the following provides an introduction/overview:
WHAT IS 'COMPLICATED GRIEF'/'PERSISTENT COMPLEX BEREAVEMENT DISORDER'?
At this point it would be useful to have a convenient definition to be able to offer to people regarding what this condition is and what it means to have it, however, this is particularly challenging. The condition is not easy to define and there is a significant amount of conjecture regarding diagnosis and treatment.
'Complicated Grief' is similar to 'Persistent Complex Bereavement' in that it is a trauma- and stress-related disorder. However, researchers in the medical community disagree about the terminology and diagnostic criteria for grief that is 'complicated' (as opposed to 'uncomplicated').
The following are terms that have been used both historically and contemporarily to describe grief symptomologies that are protracted and complicated:
-COMPLICATED BEREAVEMENT DISORDER
-COMPLICATED GRIEF DISORDER
-PERSISTENT COMPLEX BEREAVEMENT DISORDER
-PROLONGED GRIEF DISORDER
Although these terms may be used to denote a syndrome with similar (if not in some respects almost identical) features both 'Complicated Grief' (CG) and 'Persistent Complex Bereavement Disorder' should be treated as separate and distinct constructs, whose signs and symptoms cover a broader spectrum of grief-related phenomena than any of the former criteria sets and/or diagnostic sets (Julie Kaplow et al 2014).
'Acute', 'Normal' or 'Uncomplicated' grief can be regarded as the ordinary, healthy, appropriate reaction to a loss of a loved one. Some of the manifestations of normal grief are shock, denial, numbness, sadness, anger, mourning and eventual recovery (Craig White 2013 pp.2-3). It features a complex range of physical, emotional, social and behavioural symptoms that may vary significantly between individuals affected by it (Linda Schupp 2007 pp.10-11).
Acute responses to loss are not unhealthy or maladaptive responses, rather they are normal responses to an abnormal event. In most cases, therefore, grieving is natural and healthy and helps people to accept the loss of their loved ones, re-organise their lives and eventually move on. However, the emotions and feelings of grief as well as the situations and circumstances surrounding the process of grieving are often particularly difficult to deal with, especially when the death of a loved one was traumatic/sudden and social support networks are lacking (Linda Schupp 2007 pp.28-30).
What is 'normal'?
Grieving is common since death is inescapable and the deceased are unique and irreplaceable. People tend to mourn the death of their loved ones in different ways and over varying durations of time.
Although there is speculation as to how many bereaved persons experience complicated responses to bereavement it is contended that these occur in as many as between 3%-25% of cases in given populations (James Hawkins 2015/16). These range from normal grief reactions that become exaggerated to abnormal grief reactions that are in various ways problematic.
The number of people potentially affected by these types of symptoms may indeed be highly significant, based on published death statistics. There were 533,253 deaths registered in England and Wales in 2017, a 1.6% increase from 2016 and the highest number registered annually since 2003. As people are tending to live longer, the population is increasing in both size and age over time, therefore the number of deaths is expected to increase (Office for National Statistics - Death Registration 2017). Although there is no data available for bereavement, statistical indicators might potentially indicate higher risk categories in terms of type of death e.g. traumatic as well as identify high-risk populations e.g. adolescents/young adults.
In contextualising loss it is important to acknowledge that there can be great variability in terms of ranges of responses. These may be representative of individual, historical and cultural variations (Kenneth Doka 2008, Paul Rosenblatt 2013). There may also be related issues with a range of social factors including education, income and family cohesion (Laurie Burke & Robert Neimeyer 2013).
What is 'normal' for one person, therefore, us not necessarily 'normal' for another as this depends upon a wide variety of factors. Even people in the same family unit may have very different reactions and responses to grief over time, dependent upon a range of individual factors (Kathleen Gilbert 1996).
'Complicated' grief is usually a more prolonged grieving process that inhibits the griever’s ability to function optimally both physically and psychologically. The signs or manifestations of grief are often similar, however, the complicated grief reactions are prolonged and more difficult to reconcile (Kevin Fleming 2018). Thus the major differences between 'uncomplicated' and 'complicated' grief are based on the style of mourning, the intensity of the grief and the duration of time that the bereaved takes to grieve.
TYPES OF GRIEF COMPLICATIONS
Grief is multi-faceted and there are various 'typologies'. The following are all examples of grief complications, which may be experienced following the death of a loved one (Linda Schupp 2007 pp.13-14):
Experiencing a death in absentia i.e. not being present at the moment of death and/or not seeing the body afterwards. This may also involve not attending the funeral and/or not visiting the final resting place.
An ambiguous loss can be physical or psychological in nature. In the former case the physical body of the loved one is no longer present, in the latter case a loved one is still physically present but is psychologically absent. Often occurs without any understanding of the death itself.
Any number of deaths, bereavements and losses that occur over a relatively short space of time. The compound effects of these may be experienced with respect to different types of losses.
There is no overt expression of grief despite it being warranted due to the nature of the relationship with the deceased. May involve the suppression of painful emotions and problems with expression of feelings. Grief may be inhibited i.e. sorrow internalised rather than externalised, possibly due to societal/cultural norms.
A rare occurrence, predominantly affecting those with an underlying pathology e.g. psychotic episodes, narcissistic personality disorder. The individual usually exhibits bizarre behaviours associated with the death and the loss that have their own particular meaning(s) for the bereaved and make little if any sense to others.
Characterised by late arrival accompanied by intense emotions. No symptoms of grief present themselves for weeks or months. Although numbness is common after a bereavement a person suffering with delayed grief might not even recognise it.
This type of grief manifests itself with very intense emotions that are often overwhelming. The individual may be very traumatised and exhibit suicidal tendencies.
This can occur in two main respects: i) bereavements experienced by the individual in addition to former losses and ii) issues around bereavement/loss that parents and primary care-givers have experienced.
The perdurance of symptoms of grief for an extended period, beyond those associated with acute grief. There is conjecture as to the length of time that needs to pass for grief to be considered prolonged, however, this tends to range from 6 to 12 months. The grief does not subside long-term and remains persistently severe.
A traumatic death can serve to exacerbate the impact of the death and subsequent feelings of bereavement and loss. The death may be violent and is shocking and/or highly memorable. It is often unanticipated and as such allows the bereaved no time to prepare for the loss. Accompanied feelings of helplessness, powerlessness, lack of control and fear are common.
*Note that these types of complications may be experienced consecutively and/or concurrently in individual cases.
For more information on the differences between 'Acute/Normal/Uncomplicated' Grief and 'Complicated' Grief please use the following LINK:
Burke, Laurie & Neimeyer, Robert (2013), 'Prospective risk factors for complicated grief', in Stroebe, Margaret, Schut, Henk & van den Bout, Jan (Eds), Complicated grief: Scientific foundations for health care professionals (pp.145-161)
Doka, Kenneth (2008), 'Disenfranchised grief in historical and cultural perspective', in Stroebe, Margaret, Schut, Henk & van den Bout, Jan (Eds), Handbook of bereavement research and practice: Advances in theory and intervention (pp.223-240)
Washington DC (US): American Psychological Association
Gilbert, Kathleen, (1996), "We've had the same loss, why don't we have the same grief?” Loss and differential grief in families, Death Studies 1996 20(3) pp.269-283
Rosenblatt, Paul (2013), 'The concept of complicated grief: Lessons from other cultures', in Stroebe, Margaret, Schut, Henk & Van Den Bout, Jan, Complicated grief: Scientific foundations for health care professionals (pp.27-39)
Schupp, Linda (2007), Grief: Normal, Complicated, Traumatic
Eau Claire, WN (US): Pesi Publishers
White, Craig (2013), Living with Complicated Grief
London: Sheldon Press
'Persistent Complex Bereavement Disorder DSM-5' by Kevin Fleming, retrieved from Theravive www.theravive.com/therapedia/persistent-complex-bereavement-disorder-dsm--5, Article accessed on 5th November 2018
'Complicated Grief - how common is it?' by James Hawkins, Good Medicine www.goodmedicine.org.uk, Originally added 24th September 2015, Updated 28th January 2016
Office for National Statistics - Deaths registered in England and Wales: 2017 (Release Date: 18th July 2018)
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