Reading G

Pomeroy, E., & Garcia, R. (2009). Complex grief in adults. In The grief assessment and intervention workbook: A strengths perspective (pp. 84-93). Cengage Learning.

There has been some discussion in the bereavement literature about the definitions of normal, complicated, and traumatic grief experiences. Some of the terms used to describe grief reactions that do not result in life-enhancing outcomes have been “complicated,” “abnormal,” “pathological,” “unresolved,” “distorted,” and “traumatic” grief reactions. These specifiers attempt to distinguish this set of symptoms from expected grief reactions. Despite the efforts to classify these responses to loss, there is no clear consensus on the terminology and associated symptoms of this grief condition. Although there are certain symptoms that appear to be commonly associated with “normal” versus “abnormal” grief reactions, it seems more likely that there is a continuum of bereavement reactions that could legitimately be called traumatic or complicated based on the individual’s unique perceptions of the events related to the loss.

Sprang & McNeil (1995) describe traumatic grief as when “reactions to loss are intensified and/or extend beyond the established guide-lines for bereavement” (p. 56). The authors note the addition of posttraumatic stress disorder (PTSD) symptomatology to the diagnostic criteria for normal bereavement as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a more precise definition of traumatic grief. Other researchers propose that complicated grief is distinct from VISD, major depressive disorder and adjustment disorder and warrants its own category in the DSM (Lichtenthal, Cruess, & Prigerson, 2004). They associate complicated grief with “enduring psychological and physical dysfunction” and maintain that it “deviates from expected and culturally-sanctioned grief reactions” (p. 658). Similarly, some researchers suggest that traumatic grief should be a separate diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM IV-TR), which would differentiate it from Bereavement, a V coded category of the diagnostic manual (Brom & Kleber, 2000).

Rando (1993) suggests that all deaths are traumatic from the perspective of the mourner. However there are also circumstances that are clearly and undeniably traumatic from an objective standpoint. These factors can influence the depth, intensity, duration, and long-term outcomes of grief experiences.

Finally, in keeping with the strengths perspective, Ambrose (http://www.ctsn-rest.ca/I’raumaticgrief.html) provides an overview of “prolonged and/or difficult bereavement” that includes 1) circumstances of the death, 2) relationship of the mourner with the deceased, 3) the pre-death physical and mental functioning of the survivor, 4) previous history with loss and trauma, 5) social and familial support following the death, and 6) other stressors occurring during bereavement. Although the debate on terminology and criterion continues, we suggest that the ideas proposed by Rando and summarized by Ambrose serve as a useful guide for conceptualizing these types of grief experiences. For the purposes of discussion, we will use the term “complex” grief to encompass these types of grief experiences suggested by the concepts “complicated” and “traumatic.” We will use the term “complex” grief to describe a grief process that is encumbered with internal and/or external complications that interfere with the health producing growth process of expected grief. If complex grief is not addressed appropriately it can lead to life-depleting responses.

This chapter will provide an overview of situations that can lead to complex grief reactions in adults, the impact of these events on the mourner and methods for assessment and intervention.

Conditions of Complex Grief

Circumstances that are likely to lead to complex grief reactions include suicide, homicide, stigma-related illness, violent crime, natural disasters, and terrorism. Often, the mourner’s perception that the death could have been prevented is the catalyst for complex grief responses. With a stigmatized death, society may “signal that the bereaved doesn’t have a legitimate right to grieve the loss by making the mourner feel ashamed” (Sprang & McNeil, 1995, p. 139). As with expected grief reactions, the mourner’s pre-death relationship with the deceased influences the severity of the impact. Other outside factors that impinge on the functioning of the mourner can contribute to complex grief when a loss occurs. For example, financial strain, relocation, loss of job, familial disruption, and medical problems can stretch the mourner’s capacity to cope effectively with the loss. The trauma and grief experienced by the students during and following the Virginia Tech shootings in 2007 is an example of how external factors can influence the grief experience toward one that is more complex in nature. For example, the campus climate following the deaths led many students to need support from family, friends, and mental health professionals. Not only did many of these students lose friends and classmates, but they also lost their sense of safety and community stability. Consequently, the ability to cope with a disaster of this magnitude demands much more attention than when coping with an expected grief experience. The mourner’s past experience with traumatic events, their familial and social support systems, their mental health, and access to resources may also influence the complex grief experience. The following sections will describe the areas of functioning that should be examined during an assessment by the practitioner. Although some of these responses are common with expected grief reactions, with complex grief the responses are chronic, more intense and may present clinically significant disruption in social, occupational, and other important areas of functioning.

Impact of Complex Grief

Complex grief can have an impact on the mourner in a myriad of ways with varying degrees of severity. Unlike expected grief, complex grief creates significant and prolonged distress, stretching the mourner’s internal and external resources to cope with the turbulence it produces. Individuals who are experiencing complex grief may exhibit both life-enhancing responses to the loss and life-depleting responses. As explained in Chapter 1, life-depleting grief reactions are those responses and circumstances that act as impediments to the expected grieving process and interfere with the mourner’s ability to live a fulfilling life. Rando (1993) delineates the following factors as clinical indicators of complicated mourning that we consider to be life-depleting reactions.

Indicators of Complicated Mourning

1. Hypersensitivity to experiences of separation and loss.
2. Hyperarousal and overactivity aimed at suppressing anxiety related to grief issues.
3. Anxiousness about death of self and/or loved ones
4. Prolonged, excessive, persistent and un-realistic idealization about the deceased or relationship to the deceased.
5. Tenacious obsessions and rigid compulsions about the deceased and the loss.
6. Prolonged lack of emotional expression or feeling regarding the loss
7. Avoidance behaviors in social relation-ships due to fears of further loss.
8. Engaging in self-sabotaging relationships following the death.
9. Substance abuse or other self-sabotaging behaviors.
10. Post-traumatic stress-related symptoms, such as numbness, alienation, depersonalization, and affective flooding.
11. Prolonged and chronic depressive symptoms such as anger, irritability, and hopelessness. (Rando, 1993, pp.152-153)

Due to the overwhelming internal and external complications inherent in complex grief, it is not surprising that many mourners respond with life-depleting behaviors in these situations.

Complex Grief and Cognitive Functioning

Often complex grief contributes to cognitive disruptions that can inhibit and distort the grieving process. A mourner may ruminate obsessively about the circumstances under which his loved one died. Intrusive thoughts and images may plague his daily activities and cloud his perceptions of normal events. He may experience confusion, distractibility, impaired judgment, memory problems, and a general lack of concentration. He becomes preoccupied with ways the death could have been prevented or thoughts of revenge for the perpetrator. If these symptoms become chronic, they can immobilize the individual and eventuate in more serious mental disorders (Pomeroy & Garcia, 2004).

Complex Grief and Emotional Functioning

Perhaps the most noticeable component of complex grief is the emotional impairment experienced by the mourner. Many of the symptoms associated with post-traumatic stress disorder (PTSD) such as hypervigilance, numbness, dissociation, hypersensitivity, emotional lability, terror, irritability, guilt, flooding, and rage are seen in survivors with complex grief reactions (AM, 2000). This, however, is not the case for everyone. For example, some individuals experiencing complex bereavement may become severely depressed and have no other symptoms. Others may experience frequent panic attacks as the primary emotional concern.

In assessing the emotional functioning of a mourner who has experienced the immediacy of a traumatic event as well as the loss of a loved one, practitioners must be attuned to the presence of both PTSD and grief. From an emotional standpoint, the survivor of trauma is attempting to process not only the loss of a loved one but the traumatic circumstances surrounding the loss. These emotional states may be intricately interwoven making it difficult to discern the extent to which grief and traumatic stress are each contributing to the individual’s emotional turmoil. In cases in which the symptoms are severe, the practitioner should request that the client obtain an evaluation by a physician to rule out any medical causes. Suicidal ideation is of particular concern and should be a component of the assessment process. Consultation or supervision is highly recommended if suicidality is suspected or present in any form.

Complex Grief and Behavioral Functioning

Individuals experiencing complex grief may display different behavioral repertoires on a continuum ranging from expressive to controlled. On one end of the continuum, the expressive individual may publicly mourn the loss of her loved one and display erratic behaviors in work, social, and familial settings. For example, the expressive mourner may talk about the death event repeatedly, exhibit restlessness, cry excessively and display boisterous behaviors such as swearing, shouting, and laughing (http://www.rapevictimadvocates.org/trauma.html). The controlled individual may work hard to maintain internal control of her emotions and external control of her behaviors. In an effort to avoid or minimize her distress, she may engage in compulsive behaviors, such as substance abuse, gambling, or excessive working, shopping, or eating. The controlled mourner may appear to be coping exceptionally well on the surface. However, beneath the surface the mourner is feeling completely out of control and is relying on these behaviors to restore stability in an overwhelming situation. In extreme cases, such as with violent homicide, the survivor could irrationally decide to avenge the victim’s death by engaging in dangerous acts, such as stalking or seeking out the perpetrator.

Complex Grief and Physiological Functioning

For any adult mourner going through a grief experience, it is important for you, as the practitioner, to explain how the person’s emotional and physical health are intimately intertwined. For persons with complex grief, this tie between emotional and physiological responses is intensified. Symptoms that are typically associated with expected grief, such as insomnia, headaches, or loss of appetite may become chronic and severe for those suffering from complex grief. Some mourners actually grieve through their bodies. In other words, a bereaved person may express her emotions through physiological responses that alert her to the stressors she is experiencing. For example, a client may come to you and during the initial interview, report that she just came from her physician’s office because she thought she was “falling apart” physically. She said she was experiencing headaches, dizziness, heart palpitations, body aches and pains, and tremors that she had never experienced prior to the loss. Upon examination, the doctor concluded that there was nothing medically wrong with the client and made a referral for counseling. You may observe that, as she begins to discuss her loss, that the physiological symptoms become noticeable. In other words, her emotional state is closely connected to her physical well-being. By helping the client understand this association between body and mind, she can begin to gain more control over her symptoms. Although this scenario is frequent in grief counseling, you will always want to recommend continual medical consultation if a client is experiencing physiological responses to the loss.

There are also clients who develop medical problems due to stresses they have experienced over a period of time and who require a physician’s care. Sometimes, the referral to a physician must come from you, the practitioner. For example, consider a particular female client in her late 40s who lost her husband and two children in a house fire. In response to the trauma and loss, she cried continuously and “snapped” at anyone who tried to help. These behaviors continued for months until her sister brought her to the counselor’s office and said, “She may not realize what this crisis has done to her but she needs someone to talk to.” The client paced back and forth in the office and cried the entire hour. It appeared that she was extremely anxious and depressed. When asked if she had seen her doctor recently, she said that she wasn’t sick. The counselor told her that she could assist her with grief counseling on the condition that she see her physician for a check-up. With this suggestion, she sat down in the chair and seemed relieved that someone could help her. It seemed like this client needed “a container” for her emotional responses that were so out of control that they were a barrier to her everyday functioning. After seeing a physician who prescribed medication for her anxiety and depression, the client was able to think and behave more consistently with her pre-loss personality. With careful monitoring, the client was able to move forward with therapy.

Obviously, not all clients who experience grief, even complex grief, require medication in order to cope with their emotions. Once again, client responses are on a continuum and each client is unique in how he/she may respond to a particular situation. A thorough assessment of the client’s pre-loss emotional functioning, history of affective disorders and current daily functioning can inform the decision about a physician’s referral for possible medication.

Complex Grief and Social Functioning

Individuals experiencing complex grief may face intensified challenges in their social environment. Although the initial response to survivors of traumatic loss may be extremely supportive, assistance, and under-standing over the long term often wanes dramatically. This may be in part due to stigma associated with traumatic deaths, such as homicide and suicide. As a consequence, the client may feel socially isolated and abandoned by friends and community. In addition, the client’s feelings of social isolation can discourage her from communicating openly about her experience and her need for support. Moreover, the client may feel that she is a minority among mourners given the circumstances of the death. For example, there are many who have experienced the loss of an aging parent, whereas far fewer family members have lost a loved one to murder or suicide. For some individuals, you, as the practitioner, may be one of the few people with whom the client can communicate her honest and deepest thoughts and feelings.

The serious disaster of Hurricane Katrina vividly portrays the difficulties survivors have in the aftermath of such a traumatic event. Social workers across the nation had the opportunity to assist many survivors of Katrina and saw the long-term impact for families who lost virtually everything they once had. Families were uprooted from their homes in New Orleans and moved to shelters in Texas and surrounding states where they had no friends, family, or community. This lack of social stability impeded the transition and increased the sense of hopeless-ness and futility many persons expressed. Although many months passed, hundreds of families were still living in shelters with no permanent residence and were struggling to meet their basic needs. As time went on, many of these individuals were re-traumatized due to governmental decisions to rescind funding for assistance. Nightly news reports showed families in great distress who had been told they must leave their temporary living situation and had no place to go. Clearly, this disaster had life-altering consequences for these individuals and families to socially, emotionally, spiritually, and cognitively recover and regain their ability to function independently. In accordance with Maslow’s hierarchy of needs, the grief experienced by these individuals will likely linger and remain unaddressed until basic needs have been satisfied. The depth of their grief can only be imagined.

Complex Grief and Spiritual Functioning

As with expected grief, complex grief may affect the mourner’s spirituality. The complications associated with a complex grief situation such as death by murder or suicide can produce spiritual earthquakes for the mourner. For example, for survivors of homicide, the questions of “Why did God let this happen?” or “Is there really a God?” may play a prominent role in their grief. Further-more, with complex grief, the mourner may become obsessed with spiritual issues that were nonexistent prior to the death. On the other hand, some individuals may find great solace in their spiritual beliefs and rely on them for their primary source of support during this critical period of time. For example, Nora lost her adolescent son to suicide. In attempting to cope with this loss, her attendance at Baha’i faith devotionals increased, as did her study of her faith. She also relied heavily on a practice of prayer and viewed her relationship with her faith as her foundation. Nora discussed her feelings following the suicide with a leader in her faith community and felt comfort and support in this relationship. She also attended an evening study circle and developed a social support network with the members of this group. Nora often stated that her faith was her “life line” during this difficult period of mourning. She sought to understand any lessons her faith might have for her amidst this tragedy.

Brian’s experience of spirituality after the murder of his wife, however, was very different. Being catholic, he initially sought out the counsel of the priest at his parish. The priest made it clear that he was unavailable to help Brian and stated that he knew nothing about homicide. Brian visited a second priest and was told that he just needed to pray for his wife. Feeling rebuffed and discounted, Brian became disenchanted and angry and felt abandoned by his faith community and by God. Brian began to question his basic beliefs and eventually left the church community. Brian stated that this was an additional loss and a crisis of meaning for him. The anger that Brian felt toward the church led to a depressive episode in which he felt suicidal. During a presentation about victims’ rights to a police force, a victims’ assistance worker recognized Brian’s anger and depression and urged him to seek counseling. Brian attributed his enhanced coping skills to the social worker who insightfully confronted him.

Spirituality, therefore, can be life-enhancing or life-depleting to the mourner experiencing complex grief. A careful assessment of spiritual issues, particularly during a complex grief experience, can elucidate the breadth and depth of importance that spirituality plays in the mourner’s life.

Assessing Complex Grief Reactions in Adults Using Standardized Instruments

In addition to the Grief Experience Inventory discussed in Chapter 3, the following scales can be used to assess symptoms related to complex grief reactions. Rather than an exhaustive list, these assessment instruments are examples of the types of scales that practitioners can utilize. The complete description of these instruments can be found in Chapter 2.

• Acute Stress Disorder Scale (ASDS) (Bryant, Moulds, & Guthrie, 2000).
• Trauma Symptom Checklist-33 (TSC-33) (Briere & Runtz, 1989).
• Mississippi Scale for Combat-Related Posttraumatic Stress (Keane, Caddell, & Taylor, 1988).
• Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez, 1979).
• Beck Depression inventory 11 (BD1-11; Beck, Steer, & Brown, 1996).
• Center for Epidemiologic Studies-De-pression scale (CES-D; Radloff, 1977).
• Hamilton Rating Scale for Depression (Hamilton, 1967).

Expected or Complex Grief? Cross-Cultural Responses to Grief

Due to the variety of ways that grief is expressed among different cultures, the distinction between expected and complex grief responses can only be made when considered within the cultural context of the mourner. Examples of culturally appropriate mourning:

• An Egyptian mother mourns her child’s death intensely for 7 years.
• A Balinese seemingly laughs and makes light of the death of a loved one.
• Followers of some belief systems feel possessed by the deceased person’s spirit.

The Influence of Culture on Complex Grief—A Case Example

As with expected grief, complex grief is not immune to cultural influences. Cultures differ widely in the ways they deal with suicide, homicide, and other traumatic deaths. These differences should be taken seriously and without judgment from the counselor. For example, a family who experiences a death caused by suicide may grieve in solitude and receive little social support. In a different culture, however, suicide may be regarded with little or no stigma and in fact be considered noble (Range, et al., 1999). You, as the practitioner must honor these differences, even when you do not understand them. The following case example, exemplifies the role of culture in a family attempting to deal with the suicide of a loved one.

Alfred Jones was a 37-year-old African-American father of three children ages 1, 3, and 7 years old. Two years ago, he was laid off from his position at the auto factory after being employed there for 18 years. His wife, Phyllis (also African American), realized he was becoming increasingly depressed and tried to get him to see a counselor. Alfred insisted that all he needed was a job and he would be okay. As time progressed, Alfred began spending afternoons at the local bar and came home intoxicated many times. Despite Phyllis’s continual pleas that he seek help, Alfred refused. It was apparent that he was embarrassed and defensive about his inability to find employment and he blamed himself for the company’s downsizing. Phyllis appealed to her church group for assistance when the family became financially destitute. Alfred was extremely angry that Phyllis had taken this action and let others know of their financial problems. Due to this feeling of shame, Alfred became sullen and refused to attend any church gatherings. One evening, when Alfred had not returned home by mid-night, Phyllis called her sister, Alice, and told her she was extremely worried. Alice’s husband went looking for Alfred. He called later to report that Alfred had been found at a local park. He was dead from a shotgun wound to the head. The coroner’s report indicated that Alfred’s death had been self-inflicted. Upon receiving the coroner’s report, Phyllis exclaimed repeatedly, “No! Not my Alfred! He would never kill himself!” Alice became worried about Phyllis because of her continued insistence that Alfred had been murdered and no one was looking for the murderer. Two months after Alfred’s death, Alice convinced Phyllis to see a counselor. Alice accompanied her sister to the first session and explained the events of the past few months. Although initially resistant to the idea of counseling, Phyllis came to trust her counselor and looked forward to their visits. The following session notes were taken by Carol Learner, the counselor.

Session 1: Ms. Phyllis Jones and her sister, Alice, were seen during an initial session today. Alice indicated that Phyllis agreed to counseling at her urging and says she is concerned that Phyllis is not dealing with her husband’s suicide. During the initial assessment, Phyllis explained that within her community, suicide is considered “taboo.” This strong community sentiment is apparently making it difficult for Phyllis to mourn the death of her husband. She stated that she cried the night that the police came to her house and told her about Alfred, but she has not cried since. On the other hand, it appears that Phyllis has strong support from the women at her church and relies on her neighbors for help with her three children. I praised Phyllis for taking the risk to come to counseling and for her willingness to discuss this complicated matter with me.

Session 2: Phyllis discussed the events of the funeral. She reported that the casket remained closed due to the condition of Alfred’s wound. We explored how this affected Phyllis and she described feeling as though the death still wasn’t real. She stated, “I still can’t believe Alfred killed himself, even though there is a little voice inside telling me it’s true. It would be easier if it had been a murder.” We discussed how a murder might feel easier for Phyllis. She talked at length about how murders are commonplace in the area where she lives and that the community openly grieves with the family. Phyllis reported that even though the women’s group at the church has offered support, she feels uncomfortable discussing Alfred’s death with the pastor. I applauded Phyllis’s self-awareness and honesty in our session.

Session 3: Phyllis talked about her worries over her three young children who keep asking about Alfred. Although the oldest child attended the funeral, the children have been told little about the circumstances surrounding the death. She also discussed how Alfred’s family seems to blame her for his death and have withdrawn from her and the children. On the positive side, Phyllis states that the other nurses and doctors at the hospital where she works have been very supportive and started a fund for her children. I noted that Phyllis seemed more open to the idea that Alfred took his own life.

Session 4: When Phyllis came to her session today she seemed excited to tell me about the events of the past week. She reported on an incident at work in which an elderly woman’s husband died of cardiac arrest. She observed the family’s reactions of grief and found herself unable to stay in the room. She says she escaped to the bathroom where she cried uncontrollably for half an hour. When her supervisor saw her later, she urged her to take the rest of the day off. Phyllis drove to the park where Alfred had been found and sat in her car crying and screaming until she was exhausted. Phyllis said, “I can’t tell you how much better I feel. I finally realize Alfred isn’t coming back and how depressed he must have been to do what he did.” Phyllis looked significantly brighter and calmer than I had seen her previously. I commented on this change and Phyllis agreed, saying, “I feel like a huge weight has been lifted. I don’t have to pretend that it was something else anymore.” Although Phyllis acknowledged that she is still very distressed about Alfred’s death, she seems more hopeful that she will get back on her feet. We discussed the benefits of emotional catharsis as well as some resources, such as a grief group for suicide survivors. Phyllis seemed open to this idea.

In sessions five through ten, Phyllis explored her thoughts and feelings about Alfred’s suicide. To help her better understand suicide, Carol gave her information about clinical depression and its effect on brain functioning, judgment and mood. They explored Phyllis’s guilt feelings for not having succeeded in getting help for Alfred. They also discussed the healing effects of grief and ways to incorporate Alfred’s memory into her children’s lives. Following session ten, Phyllis decided to join the Survivors of Suicide group. She continued to meet with Carol periodically.

This case exemplifies some of the cultural elements that may be relevant to mourners with complex grief. It is important to recognize the role of culture in your client’s response to complex grief experiences.