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Complicated Grief
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery
~ Define Complicated Grief
~ Examine the impact of CG
~ Identify risk factors for CG
~ Explore tasks for successful grief resolution
~ Loss: Change that includes being without someone or something; physical loss of something tangible like a person, a car, a house, a breast; psychosocial loss of something intangible like a divorce, an illness, a job, a dream, a hope.
~ Bereavement: comes from the same Latin root word as “to have been robbed….” i.e. to have experienced loss.
~ Secondary loss: Other losses as a result of a primary loss. Example, loss of income when bread winner dies.
~ Grief: Reaction or response to loss; includes physical, social, emotional, intellectual and spiritual dimensions.
~ Mourning: Rituals or behaviors associated with grief; i.e. courses of action in response to loss. Rando, Complicated Mourning, p. 22.

Complicated Grief
~ Symptoms
~ Separation distress involving intrusive, distressing preoccupation with the deceased
~ Traumatic stress reflecting specific ways the person was traumatized by the death
~ Avoidance of reminders
~ Intrusive painful thoughts
~ Emotional numbing
~ Irritability
~ Feelings of hopelessness and purposelessness
~ Shattered self identity
~ Failure to assimilate the loss can create an identity crisis and problems with self-regulation
~ Who am I if I am not John’s wife/Sally’s mother?
~ Who is there to protect me now that both of my parents are gone?
Complicated Grief
~ Complicated grief can be reliably identified by administering the Inventory of Complicated Grief (ICG) more than 6 months after the death of a loved one.
What exactly are we talking about?
~ There is significant overlap between grief and trauma
~ In one study, 53% of participants had significant elevations in trauma symptoms
~ Losing a therapist or discharge could trigger past CG reactions
~ The first and most pressing question in a crisis is: What just happened?
~ Immediately following is the question: How can I manage right now?
~ Finally, the larger questions of grief and meaning are formulated.
Grief Takes Time
~ Whole first year is one loss after another
~ Beware of special occasions and holidays all year
~ Uncomplicated mourning is normally 2-3 years
~ Complicated mourning may be a 5-7 year process.
~ Grief continues for a lifetime through major life milestones.
Grief impacts us holistically…
Physical responses:
~ Appetite (eating) disturbances
~ Energy, fatigue, lethargy
~ Sleep disturbance
~ Cold (especially for children)
~ Anxiety (sweating, trembling, etc.)
~ Gastrointestinal disturbance
~ Compromised immune response; increased illness

~ Confusion; “What is real?”
~ Difficulty concentrating; ex. Read the same page several times
~ Short attention span; ex. Can’t finish a 30 minute TV program
~ Difficulty learning new material; short term memory loss; ex. Income taxes
~ Difficulty making decisions
~ Lack of a sense of purpose
~ Inability to find meaning in the events and life itself

~ Withdrawal
~ Isolation
~ Searching
~ Avoidance
~ Irritability
~ Self absorption
~ Clinging/dependence
~ Angry
~ Depressed
~ Sad
~ Crying
~ Irritable
~ Afraid
~ Can’t go on
~ Death anxiety
~ Lonely
~ Relieved/Guilty/Regretful
Spiritual beliefs are challenged…
~ The question “Why” reverberates
~ Where was God?
~ If God is all powerful, why allow this?
~ If God loves me, how could this be?
~ Prayers weren’t answered…
Common and Unique…
~ Death and grief are unique.
~ Each person’s experience is his or hers alone.
~ Each experience is unlike any other.
~ So, I can never know exactly how someone else feels.
Complicated Grief
~ The term complicated grief has to do with grief that does not follow the “normal course” or process to successful completion.
Models for Normal Grief
~ Bowlby (Attachment Theory)
~ William Worden (4 Tasks)
~ Wolfelt’s 6 Reconciliation Tasks
~ Therese Rando (The Six “R”s)
~ Attachment Relationships Help Regulate Psychological And Biological Functions
~ Mastery and performance success
~ Learning and performing
~ Relationships with others
~ Cognitive functioning
~ Coping and problem solving skills
~ Self-esteem
~ Emotion regulation
~ Sleep quality
~ Pain intensity (physical and emotional)

~ Exploratory behaviors are resiprocally linked to attachment
~ Attachment and safety stimulate a desire to learn, grow and explore
~ Caregivers provide support and reassurance (Safe haven)
~ Encouragement and pleasure (secure base)
~ Among adults caregiving is at least as important as being cared for
Feeney J Pers Soc Psych 631 -648 2004

~ Loss of an attachment relationship
~ Disrupts attachment, caregiving and exploratory systems
~ Attachment: Activates separation response and impacts restorative emotional, social and biological processes
~ Exploratory system: Inhibits exploration with a loss of a sense of confidence and agency.
~ Caregiving: Produces a sense of failure in caregiving and can include self blame and survivor guilt

Grief is Work: Worden’s Four Tasks
~ Experience the reality of the loss
~ Experience the pain of the loss
~ Adjust to an environment without the deceased
~ Withdraw emotional energy from the deceased and invest it in new relationship(s)
(William Worden, Grieving)
Alan Wolfelt’s 6 Reconciliation Tasks:
~ Acknowledge the reality of the death.
~ Move toward the pain of the loss while being nurtured physically, emotionally, and spiritually.
~ Convert the relationship with the person who has died from one of presence to one of memory.
~ Develop a new self identity based on a life without that person.
~ Relate the experience of the death to a context of meaning.
~ Experience a continued supportive presence in future years. (Alan Wolfelt, Healing the Bereaved Child)
Rando’s 3 Phases and 6 Processes
~ Avoidance Phase
~ Recognize the loss
~ Confrontation Phase
~ React to the separation
~ Recollect and reexperience the deceased and the relationship
~ Relinquish the old attachments to the deceased and the old assumptive world
~ Accommodation Phase
~ Readjust to move adaptively into the new world without forgetting the old
~ Reinvest

Rando, 1993

~ Recognize the loss
~ Acknowledge the death
~ Understand the death
~ Understand the losses as a result of the death

(Rando, 1993, Complicated Mourning)
~ React to the separation
~ Experience the pain
~ Feel, identify accept, and give some form of expression to all the psychological reactions to the loss
~ Identify and mourn secondary losses

(Rando, 1993, Complicated Mourning)

~ Recollect and re-experience the deceased and the relationship
~ Review and remember realistically
~ Revive and re-experience the feelings
~ Relinquish the old attachments to the deceased and the old assumptive world
(Rando, 1993, Complicated Mourning)

~ Readjust to move adaptively into the new world without forgetting the old
~ Revise the assumptive world
~ Develop a new relationship with the deceased
~ Adopt new ways of being in the world
~ Form a new identity
~ Reinvest
(Rando, 1993, Complicated Mourning)

Rando’s Treatment Approach
~ Assess around the six “R”s and determine where the mourner is “stuck” and not making progress.
~ Base treatment on interventions that address that “R.”
~ “Explore with the caregiver the identity and roles with the lost loved one and the meaning of the relationship.” Rando, 1993, p. 181

Risk Factors for Complicated Mourning
McCall, 2004 & Rando, 1993
~ Survivor
~ Age
~ Physical issues
~ Emotional issues (pre-existing)
~ Cognitive understanding
~ Personality and character traits
~ Socioeconomic status
~ Spiritual factors
~ Nature of the loss
~ Number of losses
~ Circumstances of the loss
~ Resources available
~ Nature of the relationship
~ Length/duration
~ Importance
~ Culture/Roles
~ Quality
~ Dependence
~ Hopes and Dreams
~ Amount of Daily Change

Rando: Treatment Tips
~ Secondary victimization occurs when support systems isolate, blame, and stigmatize.
~ Multiple losses require multiple adaptations over time and make intervention very complex.
~ Parents divorce after child is murdered
~ Homogenity in support groups helps normalize experience.

(Rando, 1993, Complicated Mourning)

Remember the five areas of focus
~ Physical Needs: Warm, healthy foods and clothing; increased susceptibility to illness
~ Emotional Needs: Grief bursts of emotion, depression
~ Social Needs: Few peers can relate. Consider a group experience.
~ Cognitive: Difficulty with concentration, learning new material, attention span.
~ Write things down
~ Simplify
~ Get assistance
~ Spiritual: Beware of the phrases that can confuse and frighten… God took her; God needed an angel; Yea though I walk through the shadow of the valley of death…; The good die young; he is sleeping
~ A secondary loss is a loss precipitated by the initial loss
~ Anticipated loss can be defined as a death that is expected weeks to years in advance.
~ Common physical, emotional and cognitive reactions to anticipated loss include changes in eating, sleeping, mood, world outlook, and socialization.
~ Common reactions to unexpected loss include shock, anger and guilt
~ Details about a death should be provided if the person asks
~ Education, normalization and validation contribute to normal adjustment after a loss
~ Education about sudden loss can help people: Alleviate guilt, find closure and move on, understand what has happened and find peace, and normalize and decrease intense reactions
~ Factors that effect individual reactions to sudden loss include: Circumstances of the death, personality and character traits, pre-existing issues, nature of the relationship
~ Sudden death makes people want to understand why it happened