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Complicated Grief: From Diagnostic Formulation to Clinical Implications
As a recently formulated disorder, complicated grief refines prior conceptualizations of the challenges posed by bereavement, drawing on a burgeoning field of research and scholarship on the psychology of loss. This editorial defines the diagnosis, illustrates it with a succinct case study, and suggests some of the conceptual and empirical literature that supports this formulation. As such, it serves as an introduction to the multifaceted contributions to our understanding of complicated grief that constitute the current Special Issue.
Some 18 months after the death of her husband, Anna, age 62, describes herself as «drowning in a sea of grief.» Far from moving toward some form of recovery, she experiences herself as «stuck» in a futile protest against the impossibility of living without John, who had been the «compass» for her life for the past two decades. Without the special caring, attunement and structure he provided her, Anna feels «disoriented,» «unreal,» as if his death is «just some sort of terrible joke.» John’s relatively fast demise from an aggressive cancer gave her little time to adapt to the harsh reality of her impending loss, but Anna confesses that she spent the majority of this «warning period» actively resisting the knowledge of his eventual death, just as she continues to resist the full emotional implications of his absence. Now, she feels deeply lonely and «cut off» from others, with the exception of her concerned adult daughter, and is caught up in an angry dispute with John’s children by another marriage about the estate. Tearfully, she describes how she has «no purpose for living» since his death, and although she is not actively suicidal, she finds herself wishing that it were she, rather than he, who had died.
In many respects Anna exemplifies the diagnostic category of complicated grief, a condition whose coherence, correlates and consequences have received increasing scrutiny over the past decade in both the psychiatric and psychological literatures. As articulated most clearly by Prigerson and her collaborators (Prigerson & Jacobs, 2001; Prigerson & Maciejewski, 2006) the diagnosis of this form of debilitating and intractable grieving is both more clinically precise than the vague and sometimes unsubstantiated depictions of «delayed,» «absent,» or broadly «pathological» forms of grief that have long populated professional discourse, and better anchored in progressive programs of research. In its present formulation, the diagnosis applies to patterns of bereavement adaptation marked by persistent dysfunction in work, family or social roles over a period of at least six months, in the presence of chronic and intense yearning or longing for the deceased, and several associated symptoms of inability to accept the death, trouble trusting others, disruptive bitterness and anger, uneasiness about «moving on» with life, numbness and detachment, agitation, and (importantly) a corrosive sense of meaninglessness regarding one’s life in the present or future (Prigerson & Maciejewski, 2006). It is thus conceptualized as a form of pervasive and profound separation distress following a sundered attachment (Bowlby, 1980), one that deprives the survivor of a secure base for exploring the world as well as a safe haven from its storms and challenges, while also increasing the risk of severe and even life-threatening psychological and medical disorders.
My own interest in complicated grief stems not only from my psychotherapeutic work with clients like Anna, but also from my conceptualization of grieving as a process of reaffirming or reconstructing a world of meaning that has been challenged by loss (Neimeyer, 2005). In this view complicated grief is seen as an inability to either assimilate the ramifications of the loss into one’s prior self-narrative or system of life-orienting meanings, or to accommodate that life story or meaning system to reestablish a world that again «makes sense» (Neimeyer, Prigerson, & Davies, 2002). Together with other contemporary theories of bereavement adaptation that focus on coping styles, family communication, dual processes of oscillating between attention to loss versus restoration of life roles, and ways of (re)negotiating the continuing bond with the deceased (Stroebe, Hansson, Schut, & Stroebe, 2007), such a perspective views grieving as an active process of striving to integrate a loss into one’s life, rather than merely «recover» from it. When such integration is difficult, either as a function of characteristics of the loss itself or as a function of the person mourning it, then complicated and chronic distress can be the consequence. For example, our recent research on over 1,000 adults bereaved by either the natural or traumatic deaths (e.g., suicide, homicide or accident) of loved ones provided strong evidence that an inability to «make sense» of the loss in practical, philosophical or spiritual terms was a critical mediator between the violence of the death and the symptoms of complicated grief that commonly resulted (Currier, Holland, & Neimeyer, 2006). Such results carry helpful implications for bereavement interventions, suggesting the utility of a variety of narrative and other meaning-making procedures, either as a focus for psychotherapy in cases of serious complication, or as a form of self-help or mutual support when survivors show greater resilience or losses are less challenging.
It is to this field of contemporary research and scholarship on bereavement that the present series of articles makes a welcome contribution. This Special Issue of the Journal of the Norwegian Psychological Association offers perspectives grounded in the latest theory, recent research, and astute practice wisdom. I am confident that the important perspectives it affords on complicated grief will contribute something of value to not only our understanding, but also our clinical services to those persons struggling to reclaim their lives in the wake of loss.
Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression (Vol. 3). New York: Basic.
Currier, J., Holland, J., & Neimeyer, R. A. (2006). Sense making, grief and the experience of violent loss: Toward a mediational model. Death Studies, 30, 403–428.
Neimeyer, R. A. (2005). Widowhood, grief and the quest for meaning: A narrative perspective on resilience. In D. Carr, R. M. Nesse & C. B. Wortman (Eds.), Late life widowhood in the United States. New York: Springer.
Neimeyer, R. A., Prigerson, H., & Davies, B. (2002). Mourning and meaning. American Behavioral Scientist, 46, 235–251.
Prigerson, H. G., & Jacobs, S. C. (2001). Diagnostic criteria for traumatic grief. In M. S. Stroebe, R. O. Hansson, W. Stroebe & H. Schut (Eds.), Handbook of bereavement research (pp. 614–646). Washington, DC: American Psychological Association.
Prigerson, H. G., & Maciejewski, P. K. (2006). A call for sound empirical testing and evaluation of criteria for complicated grief proposed by the DSM V. Omega, 52, 9–19.
Stroebe, M., Hansson, R., Schut, H., & Stroebe, W. (Eds.). (2007). Handbook of bereavement research and practice. Washington, DC: American Psychological Association.