Complicated Grief
Death of a Loved One Can Provoke an Extreme Form of Grief
Sadness comes in many forms. In addition to depression, post-traumatic stress disorder and normal grief, a researcher at the Columbia University School of Social Work is studying a syndrome only recently identified as complicated grief.
Dr. Katherine Shear, the Marion E. Kenworthy Professor of Psychiatry in Social Work, has a long list of professional credentials and accomplishments including establishing the first clinical research program on anxiety disorders in the Department of Psychiatry at Weill Cornell Medical College. But she says the work she's doing today in the field of complicated grief is by far the most gratifying.
After colleagues identified the syndrome in the early 1990s, she developed and tested a novel treatment for the condition. This research culminated in June 2005 in the publication of a landmark study showing the efficacy of the treatment. "We had to think about what is different and what is similar about this from depression, post-traumatic stress disorder — which it does resemble — and normal grief," Dr. Shear says.
Complicated grief is a reaction characterized by the inability to accept the death of a loved one. Those suffering from the syndrome experience persistent, intense yearning for their loved one to the point of preoccupation. They may enter states of reverie alternating with an opposite tendency to get upset by memories of the deceased and try to avoid situations that trigger them. The syndrome also may include suicidal thinking and behavior.
Though it has been estimated that 10 percent to 15 percent of the bereaved population suffer from complicated grief, the condition is only starting to get attention. The subject was the focus of a recent article in The New York Times, (See article: http://www.nytimes.com/2009/09/29/health/29grief.html). Until now, complicated grief was not considered a mental disorder but rather an aspect of an existing disorder. However, studies have clearly differentiated complicated grief from mood and anxiety disorders and it is currently being considered for inclusion in the DSM-V, the American Psychiatric Association's handbook for diagnosing mental disorders, due out in 2012.
With approximately 35 million widowed Americans over the age of 65, Dr. Shear estimates that 10 percent of this population, more than 3 million people, suffer from complicated grief, which she calls "a significant publichealth problem for older adults."
But to understand complicated grief, first you have to understand uncomplicated grief.
Dr. Shear explains uncomplicated grief as a natural process of grieving that involves "upheaval in life" andgreat emotional pain. But after six months the majority of people are generally progressing and coming to terms with the finality of their loss. While the grief never really ends, people are able to resume their daily activities and integrate the loss into their lives.
By contrast, people suffering from complicated grief might avoid things that trigger the pain of the loss. They might experience repetitive thoughts that the death did not have to happen or could have been avoided, or feel that life cannot go on without their loved one.
"Basically, complicated grief is aform of grief in which the acute reaction to a loss just continues without progressing, and it does so because there's something about the circumstances of the death or some aspect of the situation after the death that gets people derailed so they are focusing on a side issue, and/or trying to avoid as much as possible thinking about or dealing with the finality of the loss itself."
A case study: Four years after the death of her husband from a chronic illness, Sara couldn't accept the finality of her loss. She had not had a positive model of marriage from her own parents, and she never expected to find such a loving spouse. To add to her stress, she was also taking care of an elderly aunt who was dying of cancer, and she was not with her husband when he died, even though she had been with him throughout his illness. She was unable to forgive herself for not being present when he passed away. Unable to move forward in her life, she sought treatment for the syndrome that was eventually diagnosed as complicated grief.
 |
Dr. Katherine Shear |
Though at this point there is not a great deal of data, Dr. Shear says those who suffer from complicated grief have usually lost someone very close with whom they shared a strong and positive relationship. While the natural grieving process includes relying on one's social group for support and companionship, those suffering from complicated grief often don't have that support network or feel estranged from people in their lives who may want to help.
Dr. Shear's treatment approach — a 16-week program — is currently being tested in two clinical trials funded by the National Institute of Mental Health. The goal of the treatment is to revitalize the normal grief process to help people come to terms with their loss and resume the lives they led before their loved one died.
The first study was completed in Pittsburgh in 2005. Another clinical trial focusing on participants 60 and older is currently underway at the New York Psychiatric Institute. A third study in New York, Boston, Pittsburgh and San Diego will examine the efficacy of the treatment when administered with antidepressants.
"The therapy makes the assumption that the person needs to have someone in their life to really be there to both listen and kind of help gently move the person through the grief process," she says. "We do that using a very open, kind relationship with the person and by using specific strategies and techniques."
One of the techniques, a modification of an intervention used to treat post-traumatic stress disorder, is asking the person to tell how they learned about their loved one's death. The story is tape recorded and the audiotape is sent home with the study participant, who is asked to listen to the recording in between sessions.
The clinical trials have yielded positive results for participants, helping them to envision a future that may once again include joy and satisfaction. Dr. Shear hopes clinicians will become increasingly aware of complicated grief and the ways in which it can be treated. She is optimistic that inclusion in the DSM-V would lead to additional research and education for clinicians in the field.
"Bereavement is something that everyone experiences and yet most people feel fearful of the strong emotions that accompany acute grief," she says. "That's one reason why research has lagged behind other areas in mental health. There are a lot of suffering people who can really benefit from working with someone who knows how to help them. For a social worker it is one of the most rewarding areas of work you can do."
"Bereavement is something that everyone experiences and yet most people feel fearful of the strong emotions that accompany acute grief."