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Mental Health

Grief—Complicated? Or Not?

Kay Johnson, MA, BHSc (Psychiatric Nursing), RN

Visions Journal, 2007, 3 (3), pp. 14-15

 

As a mental health worker and as a bereavement consultant, I have struggled to clearly understand if a griever is experiencing complicated grief—recognized by the medical community as a psychiatric condition1—or not. Is it complicated grief with already-present mental health and/or addiction issues? Or is it the natural expression of grief exaggerated by these issues?

When does complicated grif occur?

I believe that complicated grief occurs when the death has added emotional trauma.

According to Dr. Therese Rando,2 probably the leader on complicated grief, three situations can complicate grief when someone close dies:

  • the death threatened their own survival

  • the death is sudden and shocking, with mutilation of people other than a loved one

  • the death is the traumatic and/or mutilating death of a loved one

What is the medical view of “complicated grief”?

The medical community views complicated grief as a major depressive episode.1 The bereaved person may think the sadness is ‘normal,’ but seeks professional help for relief of associated symptoms such as insomnia. A diagnosis of major depressive disorder is generally not given unless symptoms are still present after two months.1

The duration and expression of ‘normal’ bereavement varies considerably among individuals and/or cultural groups. However, the presence of certain symptoms, not characteristic of a natural response, may point to a major depressive episode. These symptoms include:1

  • guilt about things other than actions taken or not taken at the time of the death

  • thoughts of death other than feeling that he or she would be better off dead or should have died with the deceased

  • feeling that everything bad happened because the survivor deserves it

  • much slower thinking and physical abilities

  • unable to do the usual tasks of daily living or job requirements

  • hallucinatory experiences other than transiently hearing the voice of, or seeing the image of, the deceased person

Symptoms of avoidance, numbing, increased arousal, depressed mood, somatic or sexual dysfunction, guilt or obsession, addiction or other related symptoms may also be present.

Is it? Yes or no?

I’ve seen all of these behaviours in people who didn’t have a mental illness before the death and who didn’t experience a complicated grief situation. Corporate presidents and school-age children find themselves unable to remember how to use the telephone. Those usually meticulous about their appearance wear dirty, wrinkled clothes. Some may say this is a major depressive disorder if it lasts longer than two months, as noted above. However, I know that sometimes it takes months for a griever to feel like they can get going with life again.

People with mental health or addiction issues have usually had many losses including secondary losses related to their illness: (e.g., loss of income, relationships, employment, status, self-esteem and/or control, and losses due to discrimination and/or victimization). Often, in this population, I have seen unsupported, unresolved loss through death early in life. Not dealing with this early grief is frequently the main reason there is a mental health condition and/or increased use/misuse of alcohol and other drugs.

NOT necessarily complicated grief

Dr. Rando created a list of symptoms that are often mistaken for complicated grief, or incorrectly thought of as abnormal responses to loss.2

  • Feelings or unresolved conflicts coming up from past losses that have or haven’t been dealt with. This is a natural response for any griever. Often, a small loss triggers the feelings of past losses.

  • Sadness is not the strongest emotion. Instead, it could be anger, guilt or frustration. There may also be physical reactions, such as sleep problems; social reactions, such as wanting to be alone a lot; or behavioural reactions, like sobbing frequently or constantly checking that the environment is safe.

  • Feeling like a part of them died with their loved one or that something is missing from themselves. This may be more exaggerated if the loss had traumatic circumstances.

  • Feeling sorrier for themselves than for the person who died, or seeming to continue the relationship by, for example, talking about the deceased in the present tense. Again, these are natural reactions.

  • Keeping parts of the home as it was before the death to keep the memory alive. The bereaved person may continuously say or do things so that others will not forget the person who died. They may resist changing things that were in place before the person died, such as not wanting to move or take a new job.

  • Worrying about the chance that they or other loved ones may die. Or being resentful that a bad person didn’t die instead of this good person. They may get angry if they believe others are not grieving enough. These are common reactions in grieving.

  • Experiencing temporary periods of intense, fresh grief long after the death. This is natural.

Those with complicated grief, however, may experience some aspects of mourning for many years, if not forever. They may also have a course of mourning that does not decline with time.

A Challenge

The challenge of supporting a griever with a mental health issue and/or addiction is to be able to recognize the natural grief process for what it is. And to avoid enabling the griever to use their grief as an excuse for unacceptable behaviour. In the period after the death, the griever often has difficulty concentrating, gets frustrated more easily, and feels a loss of personal power or control. It’s important to find ways to increase the griever’s feelings of regaining control, but it’s also important to maintain the healthy boundaries of responsibility for actions.

 
About the author

Kay is the Director of Griefworks BC, a provincial bereavement resource and referral centre housed in the Children’s and Women’s Health Centre of BC. She has many years of experience working in mental health and in palliative care and now focuses on bereavement program development.

Footnotes:
  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR) (4th ed., text revision). Washington, DC: Author. Note: See under Bereavement (CodeV62.82); it is referred to as “Major Depressive Disorder.”

  2. Rando, T.A. (1993). Treatment of complicated mourning. Champaign, IL: Research Press

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