Not ‘Normal’ Anymore?: Complicated Bereavement

Posted on April 14, 2012 by

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file0001259911092I am not just the founding mother, but am also the most decorated member of my children’s fan club.

At rallies I come equipped with buttons, balloons and noise-makers, wearing electric blue shirts with the kids’ names inscribed.  I’m a complete embarrassment, but I want my support known. Their spouses can’t hold a candle to me. (I think they’re scared off by my unbounded enthusiasm.)

But if you asked me under oath whether my children were ‘complicated,’ I’d really be forced to say yes. There’d be no way around it. [Then, like Dobby of Harry Potter fame, I'd punish myself for my truth-telling, of course.]

But what strikes me as odd in the discussion of bereavement, is that the opposite of ‘complicated’ bereavement isn’t ‘simple;’ it’s ‘normal.’ [If you asked me if my children were normal, I'd enthusiastically tell you, 'yes, at least 50% of the time, in a good year.']

And this distinction matters greatly, for the ‘normal’ bereaved tend to recover on their own, in the course of time. In fact, research has shown that therapeutic interventions for these mourners are not helpful,  and, one study found, proving that science is, once again, stranger than fiction, services might even be detrimental [see "Interventions For Mourners–and Why Sometimes Research Can Be A Real Downer"].

However, ‘complicated’ grief requires–and is responsive to–intervention.

So what is normal [and I ask myself this question a lot, and find it's kind of a moving target]?

Well, normal grief is actually the more difficult of the two to define, as mourning is as unique as the individual, and each person will process loss in their own way.

All recognize that even ‘normal’ bereavement symptoms can manifest as similar to depression. There can be intense sadness, anger, disturbed sleep and appetite, feelings of loneliness and isolation. But the third edition of the Diagnostic and Statistical Manual of Mental Disorders, where mental health professionals turn for diagnosis and treatment ideas, defines normal grief as “not attributable to a mental disorder.” What keeps it from being one?

“Given enough time and distance, the heart will always heal.”~ Laura Fitzgerald, Veil of Roses

It seems to boil down to time.  Thus many define ‘normal grief’ as grief that displays itself in many ways, but begins to fade into acceptable coping mechanisms within 6 months. William Worden, Ph.D., wrote about the tasks of mourning in his touchstone text Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner. He provides an even greater reprieve, counting these symptoms and others–withdrawal, hostility, physical symptoms–as normative as long as they dissipate within a year.

But sometimes the mourning process goes awry, and the bereaved doesn’t adapt and come to a place of acceptance. Horowitz et al in their article Pathological grief and the activation of latent self images,” define pathological (and we’ll use that interchangeably with ‘complicated’) grief as “the intensification of grief to the level where the person is overwhelmed, resorts to maladaptive behavior, or remains interminably in the state of grief without progression of the mourning process towards completion.” It is when, given enough time and distance, as Laura Fitzgerald writes, the heart fails to heal.

It is easy to theorize explanations for how the slide from ‘normal’ to ‘complicated’ bereavement can happen.  Most simply, perhaps, Worden suggests, is the personality of the bereaved. A person with a rigid personality structure, or who tends toward depression anyway, will clearly be more of a candidate for complications in bereavement.

Another explanation is difficult circumstances surrounding the death. Worden’s example is multiple losses within a short period of time, but I would add unresolved cause of death, such as a suicide, or when a body isn’t found, or when masses of people are killed in devastating events: a holocaust, a tsunami, a destructive hurricane. Or, less dramatic but equally problematic, the bereaved may have fought with the deceased and never worked through that anger. Or the mourner may discover facts about their loved one that shed an entirely different light upon the mourner’s understanding of the deceased–but there is no way to work through what may be perceived as a betrayal. I plan to address Reeve Lindbergh’s, daughter of Charles Lindberg, experience with this type of complication in a later post.

Examples abound of causes for complication in grief. I had one client whose husband busted out in trading, and somehow failed to inform her of this relevant information. He kept his counsel for almost 6 weeks, even as they planned their yearly trip to stay in the apartment they co-owned with their grown children,  in a highrise building in the heart of Manhattan.

They had scarcely set down the suitcases when he said he wanted to step out and enjoy their magnificent view–and jumped 110 floors to his death.

Her furor was uncontainable. “I swear, Candida, I swear, if he came back today I’d kill him myself for what he’s done to me and to the children. I will never forgive him.”

Welcome to a case of complicated bereavement.

My client Jean’s 15-year-old son thought it’d be a lark to take out his father’s brand new BMW for a joyride–the car just called to him. So he picked up his best friend Joey and they joy-rode–right into the path of oncoming traffic. The corpses were mangled beyond recognition. Joey’s parents, former close friends, are threatening to sue, and Jean’s feelings of loss, of anger, of betrayal, of disbelief–at her son, and her former friends–are so profound and intertwined, that her bereavement is anything but simple.

And Jeff, a middle-aged man, spent his life as far back as he could remember seeking his distant father’s approval. He had pushed himself beyond what he thought he could achieve–finished higher in his med school class, made a bigger name for himself as a cardiologist, made more money, bought larger homes and decorated them lavishly–but approval had never been forthcoming. At each achievement–at his Phi Beta Kappa ceremony from Harvard, at his graduation from Yale medical school, when he bought out his partner in practice and established himself on his own, when he was voted, year after year, as one of America’s Best Doctors–he had been met by a stony silence from his father John, and the expression that indicated a vague sense of disappointment. As long as John lived, Jeff believed he would one day receive the approval, would one day be told, in some way, that he had made John proud. And when John died, reserved and disapproving to the end, Jeff mourned not just the death of a father, but loss of the opportunity forever to be a worthy son. Distant though the two men had been, Jeff’s mourning was nonetheless complicated.

Ann Berger, with her co-authors of the text Principles And Practice of Palliative Care And Supportive Oncology, provides a framework for diagnosing complicated bereavement. If    if all the following of her criteria are met–the lucky bereaved has moved out of the realm of ‘normal’ and into a ‘complicated’ world.

“Criteria for Diagnosing Complicated Grief

Criterion A: chronic and persistent yearning, pining, longing for deceased
Criterion B: the person must have 4 of the following 8 symptoms at least several times a day to a degree intense enough to be disruptive and distressing
1. Trouble accepting the death
2. Inability to trust others
3. Excessive bitterness or anger related to the death
4. Uneasy about moving on
5. Numbness/detachment
6. Feeling life is empty or meaningless without deceased
7. Bleak future
8. Agitated
Criterion C: the above symptom disturbance causes marked and persistent dysfunction in social, occupational, or other important domains
Criterion D: the above emotional disturbance must last at least 6 months”

More generally, all definitions of complicated bereavement focus on the mourner’s lack of improvement and adaptation over time, and the lack of ability to function and perform daily abilities.

I harp on the definition, for it matters greatly that people can identify when their grief has slid out of the normal realm. Complicated grief is highly responsive to therapeutic interventions, so if you as a mourner find you meet the criteria for complicated grief, or haven’t adapted in a satisfactory fashion 6 months to a year after your loss, it is time to look into support services, whether it be individual therapy (of any kind–psychotherapy, CBT, CGT, etc) or group support.

It is no crime to be complicated–my favorite kids fit that bill perfectly. But being complicated in grief requires action on your part to seek help, so that you may learn to cope and adapt, and return to some semblance of functioning life, for you, for all those who love you, and to honor the memory of the deceased.

References:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM III), Third Edition. American Psychiatric Association: Washington, D.C., 1980.

Berger A, Portenoy R, Weissman D. Principles and Practice of Palliative Care and Supportive Oncology. Baltimore: Lippincott Williams & Wilkins, 2002.

Horowitz MJ, Wilner N, Marmar C, Krupnick J. Pathological grief and the activation of latent self-images. American Journal of Psychiatry 1980; 137:1157-1162.

Worden J. Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner. New York: Springer, 2008.