What is complicated grief?

In real life, all grief is complicated. Dynamic. Complex. Multi-layered.

In therapy, grief may or may not be complicated. Uncomplicated grief is when someone goes through the journey of grief in a way that does not hurt them or someone else. Those with an acute grief response will make adjustments and assimilate their grief in a specific time frame that makes sense to their situation.

Complicated grief, on the other hand, does have certain signs and symptoms. One of these is a struggle to move from acute grief to an integration with thoughts, feelings, triggers, and memories. Complicated grief is also called Prolonged Grief Disorder, a term found in the Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

An inability to accept the reality of someone’s death is another symptom of complicated grief. This includes the person knowing the person has died. A person’s mourning becomes dysfunctional as they are stuck in acute grief. The “if only” thoughts permeate the conscious. If only I had said this to him. If only I had been there more. If only I didn’t go to work that day. If only they drove with me instead of the friend.

Another part of complicated grief is the inability to reinvest in goals and life plans. The reinvestment becomes challenging. Any reminders about the death, or anything surrounding the death, are avoided at all costs.

Katherine Shear, from whom most of this material originates, coined the acronym DERAILERS. Those are listed below in bullet form for you to see each one.

Difficulty being able to let go of doubts that I was able to do enough for the person who died.

Embracing thoughts and beliefs about grief that make me want to alter or control it.

Ruminating about how the death was unfair, wrong, or avoidable.

Anger and bitterness that I can’t resolve and let go of in a healthy sense.

“If only” thoughts about alternative scenarios that could have happened between the deceased and the person, for the deceased, or solely the person grieving.

Lack of faith in the possibility of an optimistic and inviting future.

Excessive conscious actions to avoid grief or reminders about the loss.

Resistance to allowing others to help makes me feel further hurt and lonely.

Survivor guilt is the final one. I may feel strange, uncomfortable, or wrong in feeling happy, joy, satisfaction, or making plans.

Most parts of the DERAILERS are typical responses in the grieving process. This is especially true at the beginning of the grieving. However, if the responses do not relent, they could lead to complicated grief. There are structured approaches to dealing with complicated grief, such as the Brief Grief Questionnaire, PG-13: Inventory of Complicated Grief - R, and Inventory of Complicated Spiritual Grief. Links to these three are below in the references section.

It is suggested to speak with a therapist well-versed in working with folks who experience complicated and uncomplicated grief. One of the assessments could prove helpful in learning where you are in the grieving process and the direction for treatment. Collaborating with a therapist on these assessments would allow them to ask further questions and clarify existing ones. It would be best if you spoke about the results of any assessment with a qualified mental health professional.

Complicated grief does not mean you are grieving wrong. It means you are experiencing grief in a way that’s not beneficial to your healing. Be gentle on yourself if you are experiencing complicated grief, and know that there is help out there professionally and on a peer support level with groups in the local area and virtually. I would suggest speaking with your therapist about the group possibilities and understanding what is available in the local community. There are structured treatment interventions for complicated grief.

Seek out the support you need. Grief does not have to be experienced in an isolated environment. Support is available. I sincerely hope you find the help you need.

References

Shear, K. (2011). Complicated grief treatment: The theory, practice, and outcomes. Bereavement Care, 29(3), 10-14.

Shear, K. (2020). HEALING milestones: What grievers can expect. Grief white papers series. New York: Columbia University.

Shear, K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N. Meert, K., Schiff, M., O’Conner, M….Keshaviah, A. (2011). Complicated grief and related

bereavement issues for DSM-5. Depression and Anxiety, 28, 103-117.

Assessments

Inventory of Complicated Spiritual Grief 2.0 (Burke et al.) - https://www.tandfonline.com/loi/udst20

PG-13: Inventory of Complicated Grief - R (Prigerson et al.) - https://endoflife.weill.cornell.edu/sites/default/files/pg-13.pdf

Brief Grief Questionnaire (Center of Complicated Grief; Shear et al.) - https://complicatedgrief.columbia.edu/questionnaire-brief-grief/