- The Columbia Center for Complicated Grief
- Grief and Adapting to Loss
- Examples of grief “stuck points” that derail adaptation
- Grief disorders and PTSD
- Complex or prolonged grief disorders
- Post-traumatic stress disorder (PTSD)
- Finding out if someone is suffering from a grief disorder or PTSD
- Help from a Sudden case worker
The Columbia Center for Complicated Grief
Grief is the response to losing a loved one; it contains thoughts, behaviors, emotions and physiological changes. When the loss is permanent, so too is grief, but its form evolves and changes as a person adapts to the loss.
People have natural ways of adapting to loss, usually with the support of friends and relatives, and everyone does it in their own way. You can think of healing after loss as analogous to healing after a physical wound.
The loss, a physical injury, evokes pain which can be very strong. Physical injuries activate a healing process. Loss does too. Wound healing can be delayed and so, too can the process of adapting to loss.
When this occurs, grief can be pervasive and prolonged, dominating a bereaved person’s life with an undo influence on their thoughts, feelings and behavior.
Grief and Adapting to Loss
Acute grief occurs in the early period after a loss and usually dominates the life of a bereaved person for some period of time; strong feelings of yearning, longing and sorrow are typical as are insistent thoughts and memories of the person who died. Other painful emotions, including anxiety, anger, remorse, guilt or shame are also common. Activities are often focused on doing or not doing certain things to try to deal with the loss.
Adapting to loss entails accepting the reality of the death and restoring the capacity for wellbeing.
Accepting the reality includes its permanence and the permanence of grief, a changed relationship to the person who died, and the many other changes that accompany the loss.
Restoring the capacity for wellbeing includes a sense of autonomy, competence and relatedness so that the future holds possibilities for a life with purpose and meaning, joy and satisfaction.
Integrated grief is a lasting form of grief that has a place in the person’s life without dominating it or being overly influential in thoughts, feelings or behavior.
This form of grief is usually bittersweet and can be helpful in learning and growing in life.
When grief is integrated it mostly resides in the background, but it’s often activated on certain calendar days, life events or with unexpected reminders of the loss. This does not mean that a bereaved person has not adapted to their loss.
Prolonged grief disorder (PGD) is a form of grief that is persistent and pervasive and interferes with functioning.
It’s characterized by persistent intense yearning, longing and/or preoccupation with thoughts and memories of the person who died, along with other symptoms such as identity disruption, a marked sense of disbelief, avoidance of reminders of the loss, intense emotional pain related to the death, difficulty engaging in ongoing life, emotional numbness as a result of the death, feeling life is meaningless because of the death, or intense loneliness as a result of the death. Prolonged grief continues to dominate a bereaved person’s mind. The future seems bleak and empty, and the bereaved person feels lost and alone.
Note: Most mental health training does not include information about prolonged grief.
However, trainees may be taught that grief is most ly to be especially difficult when there was an ambivalent relationship to the person who died. This is a misconception.
Instead, while it is possible that there was a conflicted relationship with the person who died, we find that for most people with PGD, their relationship was especially strong and rewarding.
Examples of grief “stuck points” that derail adaptation
Acute grief is a complex, multi-faceted experience that is often powerful and disruptive. Our initial reaction is to try to protect ourselves from the much unwanted consequences of the loss of a loved one.
We do this with some automatic defensive responses, such as protest, disbelief, imagining alternative scenarios and engaging in experiential avoidance.
In the words of John Bowlby, “When a situation occurs which we evaluate as damaging to our interests or to those of persons we care for, our first impulse is to try to rectify the situation. “ Loss p. 229
This way of responding is natural and can provide some temporary respite, but is not optimally effective in the long run. We previously labeled these processes as “maladaptive” or “dysfunctional”.
While this is one way to look at the stuck points in grief, we have come to believe it is more helpful to understand them as a part of the natural grief process and to validate the tendency to experience them.
Here are typical kinds of thoughts, feelings and behaviors that can become stuck points that can derail the process of adapting to a loss.
Thoughts and Feelings
- Disbelief or protest
- Imagining alternative scenarios
- Caregiver self-blame or anger
- Judging grief
- Survivor guilt
- Avoiding grief triggers
- Inability to move forward
- Inability to connect with others
Thoughts are typically counterfactual; its natural to second guess a loved one’s death, especially if it was sudden, unexpected or untimely; most people worry about whether they are grieving in “the right way” and many dread the future in a world without their deceased loved one and/or feel uncomfortable moving forward in a positive way.
People with prolonged grief ruminate over these kinds of thoughts. Inadequate emotion regulation is another common problem for people with prolonged grief. Acute grief is typically highly emotional. Most people have a range of ways to regulate these emotions. They balance the pain with periods of respite, giving themselves permission to set the grief aside for a time.
People with prolonged grief have trouble doing this; instead, they often focus on things that increase emotional activation. Behaviors are typically related to avoiding reminders of the loss and/or escaping from the painful reality.
A bereaved person may try to feel close to the person who died through sensory stimulation and day dreaming about being with them – looking at pictures, listening to their voice, smelling their clothes, trying to recall what it was to be together. Bereaved people are often inclined to avoid places, people or activities that hold reminders of the person who died.
These behaviors are problematic when they become the only way of managing painful emotions. Regular routines including adequate sleep, nourishing meals, adequate exercise and social contacts may be disrupted, making emotions more difficult to manage.
Grief disorders and PTSD
It may be that after a while the responses being displayed by someone suddenly bereaved are ‘normal’ grief responses common following any kind of death including expected deaths, and which don’t require any sort of specialist care to aid recovery.
For example, feelings of sadness and grief, yearning for the person who died, and crying.
However, it is not uncommon, or unusual, to suffer more than this following a sudden death.
The guidance on this page provides information on disorders (health conditions) that can commonly follow a sudden bereavement, and appropriate care.
This page is quite long. However, it is meant for general guidance only and expert mental health professionals should always be used to assess anyone who might, or might not, have a mental health disorder.
To help a bereaved person access an assessment of their needs, talk to a Sudden case worker.
Complex or prolonged grief disorders
Complex or prolonged grief disorders are bereavement reactions that are more challenging than those generally suffered after bereavement, and which are chronic (they do not go away after the early weeks).
A sudden bereavement is more ly to result in these reactions than an expected bereavement.
- Excessive irritability
- Anger and bitterness, sometimes in sudden bouts
- Continued insomnia and nightmares
- Feeling of unfairness at the death or issues around the death
- Strong feelings of personal responsibility for the death, and/or unfinished business with the person who has died
- A sense that the world as they understood it has been shattered
- Intrusive thoughts about the bereavement, that happen suddenly, when trying to get on with other things
- Difficulty socialising and avoidance of social situations
- Difficulty functioning; difficulty doing daily tasks such as finding it hard to cope with stressful moments at work or stresses when caring for children
- Feelings of futility about the future: what is the point of it all? Disinterest in planning for the future
- These reactions and behaviours lasting more than two months after the bereavement
People suffering from these kinds of reactions are ly to have constant and intrusive thoughts that revolve around thinking about the person who died all the time, wanting to be with them, and seeing the person who died everywhere they look.
They may have anxious, depressive or suicidal thoughts. They may suffer phobias and fears associated with the bereavement. For example, not wishing to travel by road if bereaved by a road crash.
People with such reactions may develop addictions or increase addictive behaviours they had before, such as use of alcohol, cigarettes or drugs (legal or illegal). They may suffer weight loss or weight gain. They may have on-going physical reactions such as pains, illness, or manifestations of stress such as stuttering.
Post-traumatic stress disorder (PTSD)
PTSD is a condition that can develop following a stressful event. A sudden bereavement is definitely a stressful event .
PTSD symptoms generally start within a month , and it is thought that in about a third of cases, symptoms are still being suffered more than a year later if appropriate care is not provided.
Many of the thoughts and reactions typical of PTSD are the same as those given to explain complex or prolonged grief disorders. It is possible for a suddenly bereaved person to be defined as suffering from a grief disorder and PTSD.
People diagnosed as suffering from PTSD often have recurring thoughts about the horror of the event that has traumatised them.
This can manifest itself through vivid flashbacks, when it feels as though the event, or events surrounding it, are happening again. People with PTSD may suffer upsetting nightmares and intense distress when reminded of the event.
Exaggerated startle responses in response to perceived threats, such as loud noises, are common.
People suffering PTSD often suffer fears that similar events might happen, or even a belief that they will happen. This sense may be reinforced if the person has had more than one traumatic event happen to them in their life.
People suffering PTSD may try to avoid things associated with the event. Reminders of the event arouse intense distress and a sense of detachment and unreality.
For example, someone bereaved by a road crash and suffering PTSD symptoms may find it very hard to be near roads.
These people have a loss of a sense of safety and feel particularly powerless and isolated; but also may display self-destructive or reckless behaviour.
Finding out if someone is suffering from a grief disorder or PTSD
Family doctors care very much when one of their patients is bereaved. However, GPs may have limited knowledge about grief disorders and PTSD and appropriate assessment and treatment. If you are a GP or talking to a GP the below information may help.
Diagnosis for grief disorders or PTSD is usually carried out using a questionnaire, accepted diagnostic criteria , as defined by respected organisations such as the American Psychiatric Association or the British Psychological Society.
The USA diagnostic criteria is published in its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and in the UK, guidance on PTSD is given by the National Collaborating Centre for Mental Health and commissioned by the National Institute for Clinical Excellence.
These criteria and guidance are subject to change over time as research into grief and PTSD develops.
To consider if someone might benefit from an assessment of PTSD, for example, it is possible to consider their answers to these questions:
- Do you have very distressing thoughts or flashbacks about the traumatic event when you don’t want to, or have nightmares about it?
- Do you avoid situations that remind you of it?
- Are you easily startled and feel as though there are threats around you?
- Do you feel detached from other people or activities?
- Is it more than a month since the event?
If they answered ‘no’ to the above questions, they may still be suffering a grief disorder, particularly if they answer ‘yes’ to the below questions:
- Do you have intrusive and frequent thoughts about the death of your loved one, when you are trying to think about other things?
- Is it more than two months after the death and you are still finding it very hard to accept the death has happened and consider the future positively?
Diagnosing someone as having a grief disorder or PTSD can aid understanding of the gravity of their needs and help them to access the right treatment and also access empathetic care in the community, for example from social workers or bereavement services.
It is not a sign of weakness, or unusual, that the bereaved person is suffering a disorder, and important that they get the correct help and support.
It is essential that treatment delivered to the suddenly bereaved person for their grief disorder or PTSD addresses the sudden bereavement centrally, recognising that this is the cause of their condition.
It is also essential that treatment is devised and delivered that is appropriate for the suddenly-bereaved person’s situation. It is not uncommon for suddenly bereaved people to be suffering other life challenges that make it harder for them to recover from thoughts and reactions resulting from their grief disorder and/or PTSD.
Some challenges may pre-date their bereavement, but others may be a consequence. Some challenges may be appropriate to deal with first, before providing care for an identified grief disorder or PTSD, for example alcoholism.
Other challenges, such as some marriage difficulties, may be made easier to deal with by providing care for a grief disorder or PTSD first.
Consideration should be given to:
- the responses being displayed in the past, now, the amount they occur and therefore the amount of disruption they cause to normal happy living;
- any previous traumatic events that happened to the person that may need addressing. A previous traumatic event may not have been recovered from, and may reinforce that “terrible things happen to me and will happen again”. Or conversely, someone may have recovered from a previous traumatic event and learned from that experience that recovery is fully possible and recovery can happen again;
- the stability of a bereaved person’s personal situation; for example, their support network of friends and family, their financial stability, any problems being faced at work, and whether they have a safe home. Some factors may be apparent, and others may be hidden, such as relationship difficulties or domestic abuse;
- the responsibilities of this person; for example their work situation, or whether they are having to care for dependents such as children, elderly people, or a disabled person; and
- any other major issues in the person’s life that impacts upon them; for example, chronic physical or mental illness, or addictions.
Sometimes suddenly bereaved people have medical conditions that also make it harder to recover from their grief disorder and / or PTSD. These conditions may pre-date a bereavement or be associated with the bereavement.
Physical illnesses that are permanent and pre-date the bereavement, such as asthma, heart conditions, epilepsy or diabetes, mean there are existing pressures on the suddenly bereaved person in addition to suffering a grief disorder and/or PTSD.
Sufferers of clinical depression may be taking medication or suffering suicidal thoughts or both, again adding to the challenges faced in addition to the effects of the bereavement.
Examples of medically-defined conditions include:
- Clinical depression, often treated with anti-depressants
- Injuries, sometimes caused in the same event (such as a road crash) that caused the death
- Existing permanent illnesses, such as heart conditions, epilepsy or diabetes
- Alcohol or drug addiction
Achieving this full understanding of a person’s situation will enable carers to devise support that is tailored to the individual and therefore more ly to be of benefit. In some cases, it may be necessary to address other challenges in a person’s life, such as drug addiction, before a grief disorder or PTSD can be treated effectively.
It is usually best practice to treat traumatic grief and / or PTSD with therapy (sometimes called counselling) using cognitive behavioural techniques tailored to the individual’s needs.
This means talking through things with a therapist (sometimes called a counsellor) in a number of one-to-one sessions (usually between 10 and 25, and usually lasting about an hour each).
In these sessions it is usually the case that the suddenly bereaved person will:
- Address the event and try to come to terms with what is known to have happened. This can be achieved through talk, writing, visiting the scene, or other methods.
- Talk about any painfully-upsetting aspect of the event that is presumed (imagined) and therefore may not be true, to enable these thoughts to be corrected and stopped .
- Talk about any unfinished business with the person who has died. For example, any feelings of guilt or lost plans.
- Talk about the future and find a way to think positively about it.
The therapist assigned will need to be qualified and experienced in providing this therapy. Ask them how many times they have worked with people suddenly bereaved, and the success of their work.
It is also important for the suddenly bereaved person to feel they have a trusting and positive relationship with their therapist.
If they don’t connect well with their therapist, it is always possible to change, and suddenly bereaved people should be encouraged to keep trying therapy with a different therapist, and not be “put off” by an unsuccessful first attempt.
It may or may not be possible to get this therapy for free, quickly, or there may be delays. Sudden case workers can assist obtaining access.
Medical professionals who are not familiar with grief disorders or PTSD may suggest that prescribing drugs is the first answer, particularly anti-depressants, sleeping tablets, or anti-anxiety drugs.
Generally, while drugs may offer some immediate relief from some symptoms, this is not believed at present to be the best first route of care .
It can be harder to consider and address grief and trauma responses while taking medication.
Help from a Sudden case worker
In all cases, if you are not a medical professional and are reading this page, seek help from a Sudden case worker. With the permission of the bereaved person, they can seek an assessment from an appropriate medical professional of their needs and appropriate treatment.
- Post-traumatic stress disorder The management of PTSD in adults and children in primary and secondary care, 2005, 184.108.40.206 National Collaborating Centre for Mental Health, commissioned by the National Institute for Clinical Excellence, pub British Psychological Society
- American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed) Washington DC
- Treatment of complicated grief, Rita Rosner, Gabriele Pfoh, and Michaela Kotouová, Department of Psychology, Ludwig-Maximilians-Universitaet, Munich, Germany, 2011