It is a universal human experience. Still, some grief is especially messy, distressing, and hard to move through. “Complicated grief” affects 7–10 percent of bereaved people, according to the National Institutes of Health.
Grief can look very different between individuals, so there is no “right” way to grieve. Previous views conceptualized grief in terms of “five stages” (“denial, anger, bargaining, depression, and acceptance”). Today, experts are quick to caution against these prescriptive models, which can be harmful. They emphasize that “normal” grief often does not follow this orderly trajectory and that many people who grieve may not find closure and instead must work toward acceptance.
One of those experts is Annalee Moody, MA, NCC, LMHC, CFRC. A licensed mental health counselor, Moody previously served as director of FHE Health’s EMDR Program and worked with first responders receiving care through the Shatterproof treatment program. EMDR (“Eye Movement Desensitization Reprocessing”) is a groundbreaking therapy that has been found to be highly effective at relieving flashbacks and other symptoms commonly seen in PTSD and grief.
What is complicated grief, and how does it differ from so-called normal grief? What are the mental health effects of complicated grief, and what coping tools can help people move through it? For answers to these and other questions, you can catch highlights from an interview conducted with Moody during her work in trauma-focused treatment below.
What Is Complicated Grief?
“Complicated grief” is grief that is “delayed, exaggerated, and prolonged,” Moody said. She added that “the clinical marker or textbook definition that providers use to diagnose complicated grief” is as follows: “intense, persistent, and debilitating grief beyond 12 months;” or grief that has caused significant impairment of daily function for at least six months (“if someone can’t go to work, leave their house, or take a shower,” for example).
Complicated Grief vs. “Normal” Grief
Complicated grief, as “a diagnosable, pathological response to grief,” occurs in about “2–3 percent of the population.”
“A lot of people want to pathologize grief responses, but we have to be very careful about that,” Moody said. “Being devastated when someone dies is what’s right with you—it’s going to be hard for a long time. If it’s intense, persistent, and debilitating—when the person can’t function—that’s when we say it’s a pathology.”
Today’s clinical approaches are “not going to tell you what you’re going to feel or should feel,” Moody continued, drawing a contrast with the old “five-stages-of-grief model.” “Our tendency is to want someone to take us by the hand and say, ‘This is what you’re feeling, and this is how it ends’; but this sets us up for failure. Instead, the focus is ‘what is it that you’re feeling, and how can we deal with that today?’”
Questions of “Closure” and “Unresolved Loss”
It may be tempting to think that a key differentiator between normal and complicated grief is “closure,” or lack thereof. Moody refuted this notion:
What’s “closure” after a death? You don’t get to see your loved one go to heaven. There’s no real way to get what is closure and know the end outcome. With death, we don’t get closure.
“Certainly, there are deaths that reinforce the natural circle of life,” Moody acknowledged. Here, she was referring to those times when “someone who has lived a happy and productive life dies at an old age.”
Traumatic Grief
“Traumatic grief,” in contrast, is “any death that does not reinforce the natural cycle of life that we believe to be appropriate.” Moody continued:
When an eight-year-old gets hit by a bus—we have all these beliefs about what’s fair and true—it’s not fair. We want kids to be less mortal than adults, but they’re not. We start with an expectation that we are owed a long, happy, pain-free life, but that is not fair, reasonable, or appropriate.
First responders “don’t get insulated from the fact that we’re mortal beings,” Moody said. “Most don’t have that expectation that we’re owed a long, happy life.”
The Role of Cultural Norms
“The way that we grieve is heavily influenced by our culture,” Moody said. “What may look abnormal to you may be a very normal way to grieve in another culture. Even expected grief reactions can look different between people, so what we have to focus on is functionality.”
Causes and Triggers of Complicated Grief
What are some causes and triggers of complicated grief? “Scenarios where something is preventing you from grieving and you get stuck in the grief process,” Moody said. Some of the things that can cause that include:
- multiple deaths in proximity to you in the last three months
- disproportionate loss and responsibility at a relatively young age
- when children die
- traumatic deaths such as a sudden accident or suicide
- being unable to view the body
The Mental Health Effects of Complicated Grief
Symptoms of grief can mimic symptoms of PTSD or depression, which is why Moody emphasized the importance of screening for grief when diagnosing PTSD or depression.
“If somebody died within the last year, I’m hesitant to diagnose them with major depressive disorder,” Moody said. “If someone comes in and says, ‘I’ve had these depressive symptoms for a while since my brother died, and they got worse’—then I’ll tease out the new symptoms since he died.”
“A year is a good marker,” Moody said.
Dealing with Complicated Grief – Coping Strategies and Treatments
Focus on Basic Needs
One important coping strategy when dealing with complicated grief is focusing on basic self-care, especially in the immediate aftermath of a loss. As Moody explained:
We want to help people focus on their basic needs (eating, sleeping, bathing, etc.). Everything else is at a higher level and can wait.
Treatments for Complicated Grief
Cognitive behavioral therapy (CBT) is a commonly prescribed therapy for grief-related distress. EMDR can also be effective when grief involves traumatic loss and symptoms such as flashbacks or intrusive thoughts.
“If you think EMDR will help you have a ‘normal’ grief reaction, that won’t help you,” Moody said. “But if you’re having flashbacks or symptoms outside of a typical grief response, we’d look to address those.”
Encouragement for Those Facing Complicated Grief
“If your symptoms are problematic,” Moody said, “go see a professional who can help.”
She also noted that grief can stem from many forms of loss—not only death—and emphasized that there is no shame in seeking support.
For readers interested in further resources, Moody shared several books she has previously used in grief counseling:
- Grief Works, by Julia Samuel
- The Other Side of Sadness, by George Bonanno
- Wild Edge of Sorrow, by Francis Weller
