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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 towards acceptance.
One of those experts is Annalee Moody, MA, NCC, LMHC, CFRC. As a licensed mental health counselor and the director of FHE Health’s EMDR Program, Moody regularly treats first responders who are getting help for grief and trauma issues in our 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 grieving.
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 the highlights of our interview with Moody 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:
- multiple deaths in proximity to you in the last three months
- disproportionate loss and responsibility at a relatively young age – for example, if you’re only 18 when your parents die in a car accident and now must take care of the final arrangements and other financial and logistical responsibilities
- when children die
- traumatic deaths such as a sudden accident or suicide
- if someone is unable to view the body – “One of the reasons we have open caskets is because our imagination can be torturous, so most of the time it’s better to see what’s there and then close it. Then we know what is, instead of letting our imagination run wild.”
The Mental Health Effects of Complicated Grief
Symptoms of grief can mimic symptoms of PTSD or depression, which is why Moody is careful to screen for grief when diagnosing PTSD or depression: “We have to be careful that we’re not diagnosing PTSD or depression if the person is actively grieving a recent death.”
“If somebody died within the last year, I’m hesitant to diagnose them with major depressive disorder,” Moody continued. “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. In other words, if a person’s grief and depressive symptoms persist after one year, they are dealing with complicated grief and “reactive depression” (depression triggered by a stressful event such as the loss of a loved one, a job, or a relationship).
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. This is most important in the immediate aftermath of a loss or death. Here is how Moody described it:
We want to help people focus on their basic needs (eating, sleeping, bathing, etc.). Everything else is at a higher level and can wait.
At first, we really want people to be taking care of themselves. If our basic needs aren’t met, then the whole system starts to fall apart.
Treatments for Complicated Grief
Cognitive behavioral therapy (CBT) is a commonly prescribed therapy for grief and grief-related distress. CBT teaches clients how to replace negative thoughts with healthier ones and how to adjust to life in the absence of a loved one who has died.
EMDR can be an effective treatment for grief that involves traumatic loss and subsequent symptoms like flashbacks or intrusive thoughts, Moody said. She added that in these cases, it’s important to be clear about the expected outcome with EMDR:
If you think EMDR will help you have a “normal” grief reaction, that won’t help you; but if you’re having flashbacks or other symptoms than what we’d see in a typical grief response, we’d see if we could mitigate those symptoms.
CBT and EMDR are just two of many treatment modalities that can address complicated grief, according to Moody.
Encouragement for Those Facing Complicated Grief
What words of encouragement could Moody offer to those facing complicated grief?
“If your symptoms are problematic,” she said, “go see a professional who can help … A mental health professional can help determine if you are having an expected response or need actual treatment.”
Another source of encouragement? “Every licensed therapist has some training in grieving, so you don’t have to seek out someone who is specialized in grief therapy—but they do exist, and there are all kinds of certifications for grief and grief counseling.”
Moody was also careful to point out that grief, even complicated grief, can have more than one cause, not just the death of a loved one. A breakup, the loss of a job, or a DUI that keeps you from pursuing your life dream of becoming a judge can trigger immense grief. The reality is that loss and grief are an inescapable part of being human. There’s no shame in asking for help.
For those looking for more resources for grief, Moody shared three books that she has used in the past with clients in bereavement counseling and that are available in our Shatterproof library:
- Grief Works, by Julia Samuel, replaces the old “five stages” model of grief with some how-to insights for healing.
- The Other Side of Sadness, by George Bonanno, explores what “the new science of bereavement tells us about our loss.”
- Wild Edge of Sorrow, by Francis Weller, takes a more philosophical approach to making sense of grief and is “the most beautifully written grief book I’ve ever read,” according to Moody.
