3 When grief goes wrong
Most people experiencing a grief reaction do not need specific professional help, although everyone could probably do with as much support as they can get from friends and family. Indeed, labelling someone as ‘bereaved’ and therefore by definition different, and possibly in need of some form of intervention, may in itself be harmful. But sometimes the usual sequence of events does not go to plan; people may develop an excessively severe or extremely long-term reaction to their bereavement. For those who support the continuing bonds thesis this may be a part of their ongoing relationship with the deceased person, but within orthodox medicine, very strong or overly long responses to bereavement are frequently referred to as ‘complicated grief’ (Hawton, 2007).
In attempting to categorise and ‘pin down’ complicated grief, psychiatrists and other professional grief specialists, for example a team of American psychiatrists headed by Mardi Horowitz (Horowitz et al., 1997), have developed criteria that spell out specific features of ‘complicated grief’ (CG) in order to distinguish it from other forms of depression or more usual forms of grief reaction. The features of complicated grief are listed in the box below.
Diagnostic criteria for complicated grief
The person has experienced the death of a significant other and their response involves three of the four following symptoms, experienced at least daily or to a marked degree:
intrusive thoughts about the deceased person
yearning for the deceased person
searching for the deceased person
excessive loneliness since the death.
In response to the death, four of the following eight symptoms are experienced at least daily or to a marked degree:
purposelessness or feelings of futility about the future
a subjective sense of numbness, detachment or absence of emotional responsiveness
difficulty in acknowledging the death (e.g. disbelief)
feeling that life is empty or meaningless
feeling that part of oneself has died
a shattered worldview (e.g. loss of sense of security, trust, control)
assuming symptoms or harmful behaviours of, or related to, the deceased person
excessive irritability, bitterness or anger related to the death.
Disturbance (symptoms listed) endures for at least six months.
The disturbance causes clinically significant impairment in social, occupational or other important areas of functioning.
(Based on Latham and Prigerson, 2004, p. 351)
From a medical perspective, people experiencing bereavement exhibit various features that might indicate that they are at particular ‘risk’ of developing a complicated grief reaction. It appears more common when the death is sudden, violent or unexpected. The death of children also appears to be a trigger and death by suicide often gives rise to complex feelings. In addition, the quality of the relationship between the deceased person and the bereaved survivor may affect the form that any grief reaction takes. But do these features mean that the grief experienced as a result is necessarily ‘complicated’?
Activity 3: Complicated grief?
Read the extract below describing the way in which Sylvia reacted to a string of bereavements, then write notes in answer to these questions:
What features of Sylvia's story do you think made her vulnerable to complex feelings following the deaths she experienced?
Do you think that Sylvia meets the criteria for CG (complicated grief) as set out in the box above?
Sylvia began to experience a string of bereavements. First, her father died after a long illness during which he had developed a debilitating lung disease and had increasing difficulty with breathing. Although Sylvia had never got on particularly well with her mother, Gloria, and their relationship was distant and strained, she brought her to live with her family. From Sylvia's point of view, Gloria remained miserable and self absorbed. Sylvia and her household became dominated by her mother's problems until she herself died of a chest infection about six months later.
While her mother's affairs were still being sorted out, Sylvia was called in an emergency to the local hospital. There she witnessed the death of her only child, Lucy, after a road accident.
Three years later, Sylvia was unable to comprehend that Lucy was dead. She was convinced that the hospital hadn't done enough to save her life and she wouldn't go anywhere near the crossing where the van driver had ‘murdered’ Lucy. She remembered each of Lucy's anniversaries and clutched her toys to her chest almost all the time. She refused to talk about the events that had happened to her and would often sit for whole days at a time in Lucy's room without heat or light. She began to eat only ‘nursery food’ and was often seen talking to herself. Through her frequent tears Sylvia would claim that she was waiting to die and that then at least she would be reunited with her daughter.
How can anyone ‘get over’ such a horrible sequence of events? Is Sylvia behaving just like anyone would react, or should her reaction be labelled as ‘complicated grief’? In some situations there might not be sufficient information to be certain that the diagnostic criteria for CG were met, but with Sylvia it seems, from a medical standpoint at least, that this is what was happening.
From this perspective, she was vulnerable to developing CG because of the multiple bereavements she suffered in short succession, and the sudden violent death of her child. Having a poor relationship with one of the deceased people, her mother, could also have been predicted to cause psychological problems in the future. Thus, although the case study does not go into sufficient details about Sylvia's feelings to tick off all the relevant symptoms, it must be almost certain that a psychiatrist would give Sylvia the label of ‘complicated grief’.
The question that arises, however, is where the boundaries of what is considered ‘complicated’ are drawn. Referring back to what you learned earlier in this course about measuring grief, is it possible to quantify people's feelings and behaviours in such an objective way? And who decides what the boundaries of CG are? You can see in this activity how there are issues of authority in who decides what complicated grief is: whoever identifies what is appropriate and acceptable grieving behaviour, and for how long it should continue after someone has died, is necessarily in a powerful position. An outcome of this is an expectation that those who decide what is ‘complicated grief’ (or even ‘grief’) are the experts about people's responses to bereavement overall. One result of this has been that medical opinion is often sought by bereaved people. Pressure on the medical profession to respond with medication to bereaved people who seek help has led to a steady increase in the prescribing of drugs, particularly antidepressants and tranquilisers. However, while these pressures exist, the effectiveness of these types of medication is currently difficult to demonstrate, and for the time being many doctors choose not to prescribe a drug treatment that they feel could end up interfering with the experience of grief.