9 Sep 2022


Complicated Grief: Book Summary

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Academic level: Ph.D.

Paper type: Book Report

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Pages: 23

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Editors Margaret Stroebe, Henk Shut, and Jan van den Bout analyze complicated grief for experts in the book Complicated Grief: Scientific Foundations for Health Care Professionals . Chapter authors explore research innovations, recent research, diagnostic matters, and various interventions concerning complicated grief. The entire book offers a wider overview of the domain and implications for professionals through in book organized into 21 chapters. The present paper summarizes the major points of each chapter beginning from chapter two to chapter 20 before reflecting on these points and their impact on future practice. 

Chapter 2,3,4,5 

In the second chapter, Cooper examines various philosophies that offer insights into the complicated grief concept. In particular, the author uses these philosophies to define complicated grief. First, the authors define a disorder as something bad that happens to a person in which psychological or medical treatment will be required. The author demonstrates philosophical differences using two groups, the descriptivist and the normativism. The preceding consider the biological basis of a disorder while the latter consider a disorder as a bad thing. Based on this definition, the author argues that grief is a bad thing because it causes sadness on the part of the grieving. However, grief differs from other disorders because it also involves memories of loved ones and good times. 

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Thus, grief causes mixed feelings. Another important component of grief is that the grieving must have loved the lost person. However, grief may not be a bad thing if it involves losing a very old or very ill individual, which highlights the role of regret in grief. In particular, people grief only if they loved the individual and they regret the death. Thus, the context of the grief also matters when it comes to how the remaining people will feel about the loss. Regarding the association between complicated grief and the DSM system, the authors shows that the DSM considers complicated grief as an expected and culturally sanctioned reaction to an external event such as when a loved one dies. The author states that stakeholders should consider grief as a disorder. Nevertheless, there are disagreements regarding considering complicated grief separately as a disorder owing to the existence of different classifications. 

In the third chapter, Rosenblatt explores the cultural variations of complicated grief in which they discuss complicated grief in western cultures versus complicated grief in other cultures. The author cautions against using the cultural values of another culture to understand the values of a different cultural group. Besides, while all cultures experience complicated grief, the complicated grief idea and its clinical implications are relevant only to some cultures. In particular, some cultures do not experience problematic symptoms of complicated grief. The authors highlight the idea of deviant grieving of individuals in traditional societies in which some communities encourage the grieving to be happy. Nevertheless, in the Western culture, such practices are not practiced. Other assumptions about complicated grief are presented. They include the source of people’s grief, the cultural similarities and differences regarding grieving, and who must be healed during grieving. 

The authors also emphasize that helping grieving people from different cultures requires a consideration of the appropriate values concerning grieving in a specific culture. Understanding the expectations and values of the relevant culture offers insights into the meaning of death and grieving to the people of that culture. It is essential to understand the cultural aspect of grieving because using the cultural standards unrelated to the client’s culture can result in harmful diagnosis and treatment. It is also inappropriate to use theoretical models developed in a specific culture about complicated grief as universal models. Therefore, clinicians are advised to familiarize themselves with the client realities through careful listening as this helps them to understand the situation and offer the needed assistance. 

Rando discusses complicated grief as a unique diagnostic issue and a clinical issue in chapter 4. In particular, the author argues for complicated grief to be diagnosed separately to distinguish it from other disorders. Nevertheless, disagreements persist concerning the criteria to be used. The author notes that prolonged grief disorder (PSG) is at the core of the disagreement owing to its importance in determining complicated grief. Specifically, stakeholders hesitate in using prolonged grief disorder as the criteria for diagnosing complicated grief since as a symptom it refers to specific mourner category suffering from attachment problems. In turn, this reduces its usefulness for complicated grief diagnoses. Besides opponents consider the criteria as lacking the major variables present in complicated grief. According to the author, PGD is just one of the symptoms of complicated grief, which may not result in effective intervention. 

The author also views complicated grief based on a clinical perspective to demonstrate its complexity and the numerous symptoms involved. Four clinical manifestations of complicated grief are identified, namely symptoms/signs, syndromes, physical or mental disorders that can be diagnosed, and death. For the clinician to diagnose complicated grief, the aforementioned manifestations must be fully developed since the loss is accompanied by several interferences of certain processes of normal grief. Both manifestations must be present for a diagnosis of complicated grief to be achieved. The author also demonstrates that all forms of complicated grief consist of two major elements, connection and avoidance. A conceptual model is also presented to aid in understanding the way complicated grief develops. The model consists of eight components, including distinctive features, explanatory theories, the underlying coping, essential issues and their functioning, objectives, forms, and assumed operationalized mechanisms. The model considers the multifaceted nature of complicated grief symptoms. 

In chapter five, authors Boerner, Mancini, and Bonanno explore the topic of complicated and uncomplicated grief. They demonstrate that complicated and uncomplicated grief do not differ significantly. In particular, understanding the differences between the two concepts entails gaining insights into grief trajectories. Specifically, it is common for people to experience less complicated grief by demonstrating low depression or distress levels. In short, most individuals manage their grief successfully. Thus, it is vital to understand the reasons for some people not experiencing high distress levels when grieving. However, some people experience severe distress in the long term that results in chronic or complicated grief. The different experiences arise mainly due to individual, situational, and contextual factors, namely resilience, improvement when grieving, and the distress level for chronic grief. In particular, resilient people do not suffer from mental illness, which enables them to be ready to deal with losses positively by relaxing when thinking or talking about the lost individual. Resilient individuals usually have had a depression experience in the past through caring for a loved one. The experience enables them to be comfortable when remembering or talking about the deceased. 

Grievers can also respond to the loss chronically or with chronic depression. The preceding response occurs due to prolonged issues with emotional and cognitive distress associated with the loss while the latter occurs after the loss exacerbates the emotional issues. Inadequate mental readiness causes chronic grief while ongoing mental problems cause chronic depression. Thus, readiness for a loss is a vital component because it affects grief patterns. 

Chapter 6,7,8,9 

Dyregrov and Dygregrov support the argument that children coping with complicated grief require more assistance in chapter six. They note the lack of understanding regarding complicated grief among children under the age of 18 years and the inappropriateness of the adult diagnosis in children. In particular, children also experience the death of loved ones, which can cause mental issues, somatic issues, social and behavioral issues, and poor performance in school. Risk factors such as the need for the family to move, inadequate parenting, inadequate support, and family financial challenges increase the potential for the development of problems among children following a loss. However, factors such as the ability of the parent or caregiver to care for the child after the loss enables children to cope positively with a loss. Other issues such as functional impairment, depression, suicidal ideation, post-traumatic stress disorder, and anxiety among parents or caregivers compromise the ability of children to cope with grief. 

The authors also demonstrate the lack of a clear understanding of complicated and normal grief among children owing to the uniqueness of children. Specifically, children lack adequate experiences, still developing, and caregiver or parental responses affects them, which makes it challenging to understand grieving among children. Several interventions are suggested for grieving children, namely enhancing the capacity of parents to help children cope and psychoeducation and narrating the experienced events. It is also essential to consider other aspects such as cultural and historical context when attempting to understand grieving in children. Consequently, the authors recommend further research to offer insights into the complicated grief of children, treatment models, and assessment. 

In chapter 7, Boelen and Prigerson support the idea about complicated grief being a psychiatric condition. They identify the absence of categories for disorders related to grief in the DSM besides identifying the uniqueness of complicated grief from other disorders. They argue that prolonged grief or complicated grief has the required features to be identified as a psychiatric disorder and advocate for the inclusion of the disorder in the DSM system. In particular, a mental or behavioral syndrome characterizes people with complicated grief in which the syndrome results in clinical disabilities or distresses. Besides, the syndrome is not an anticipated reaction to stressors brought about by grief because they involve maladaptive reactions to grief. The syndrome also occurs due to an underlying psychobiological dysfunction, does not arise due to societal conflicts or social deviance, and requires valid diagnosis to ensure effective treatment. 

They also argue that considering complicated grief as a mental disorder enables clinicians to identify and treat the grieving. The authors also note the source of the current confusion regarding the criteria to be used for diagnosing complicated grief in which there are currently three major sets of criteria including the prolonged grief disorder criteria, the complicated grief criteria, and the adjustment disorder related to grief criteria. All these criteria differ from each other and the criteria used in research and clinical practice. The authors recommend further empirical studies to identify relevant criteria to be used in DSM. 

In chapter 8, Wakefield offers an opposing view regarding including complicated grief in DSM. The author questions the validity of the suggested criteria for diagnosing complicated grief owing to the numerous recommended criteria with notable variations in terms of symptoms. Some criteria sets such as the adjustment disorder related to grief identify only a single symptom, namely yearning for the lost loved one while the DSM proposes the criteria that grief should last for 12 months to be diagnosed as complicated grief. Nevertheless, there is inadequate evidence to consider complicated grief as a disorder. 

Besides, the DSM-5 definition of bereavement-based disorder is not specific owing to the presence of disorders related to bereavements such as heart failure and major depression. Besides, the author questions the sufficiency of the impairment criterion in DSM mental disorders, the appropriateness of relying on a statistical approach to defining disorders, and the appropriateness of defining complicated grief as a mental disorder. In particular, prolonged grief disorder and normal grief are not conceptualized clearly and there is no empirical support regarding symptom duration. Thus, the author argues that research does not support the inclusion of people into DSM since most people experience lengthy but normal grief. Consequently, there is a need for further research to identify strict sets of criteria for diagnosing complicated grief to avoid false positives during diagnosis. 

In chapter 9, van den Bout and Kleber argue that that the effect of including complicated grief into DSM is identical to the effect experienced when PTSD was included in DSM because both involve the specification of the necessary cause. In PTSD, the cause is psychological trauma while in complicated grief and prolonged grief disorder, the cause is the loss of a loved one. The authors also explore the benefits and drawbacks so far since the inclusion of PTSD in DSM and the lessons that stakeholders focused on complicated grief can learn when attempting to include the issue into DSM. They demonstrate that empirical and scientific work focused on conceptualizing PTSD in addition to societal developments related to chronic illnesses that war veterans experienced contributed significantly to the inclusion of PTSD into the DSM system. However, disagreements persistent and concerned several criteria for diagnosing PTSD such as stressors, the association between traumatic stressors and presenting symptoms, comorbidity issues, issues related to overemphasis of complaints, and problematic understanding of trauma and PTSD in society. 

Consequently, the authors show that the DSM system does not define mental disorders clearly, even though it has strict criteria for diagnosing mental disorders. They suggest that a clear definition of a mental disorder can be obtained by considering both empirical evidence, social factors, and financial factors. They argue that complicated grief stakeholders can learn several lessons, including the need to acknowledge suffering, consider effective treatment approaches for patients, stop focusing on including complicated grief into DSM, approach the complicated grief domain from diverse views, and consider the stressor criterion carefully. 

Chapter 10,11,12,13 

Raphael, Jacobs, and Looi also explore the way several conditions overlap in complicated grief. In particular, they examine the characteristics of complicated grief, PTSD, and depression to identify differences and similarities. It is shown that even though depression emerges in most cases involving people exposed directly to grief, the underlying stressors usually relate to PTSD. Besides, in such cases, complicated grief is comorbid with PTSD and depression. However, those who have lost a loved one experience prolonged grief disorder while those who are exposed to the loss experience PTSD. Besides, both illnesses impair normal functioning. The authors show that disasters such as wars and terrorism meet the criterion for PTSD given that they threaten the lives of people exposed to them, which can lead to grief, helplessness, suffering, and agony. 

People who witness such shocking events are exposed to traumatic experiences, grief, and loss, which results in PTSD and major depression over time. Consequently, the authors suggest that functional impairment arises only when the separation anxiety aspects of complicated grief interact with threat anxiety elements of PTSD. The comorbidity of PTSD and complicated grief pose treatment challenges due to symptom overlap, the necessity for further skills, and the additional burden to the patient. The authors recommend that counselors consider the relevant parties, the context, and understand the client experience of trauma and grief when developing treatment approaches. Counselors should also be empathetic and genuine when dealing with clients experiencing traumatic syndromes. 

In chapter 11, Burke and Neimeyer explore risk factors for complicated grief. They note that while people grieve naturally after losing a significant other, they respond differently. For example, some people are resilient and depict less mental distress while others suffer from extreme sadness. They emphasize the importance of differentiating between risk factors for complicated grief and the effects of complicated grief. In particular, the exploration demonstrates risk factors such as gender, race, and cause of death, kinship, marital dependency, and attachment style. Others include negative cognition, belief factors, social support, and worldview. According to the authors, it is still challenging to identify all the risk factors for intense complicated grief because of the conceptualizing complicated grief as a construct. In particular, it may be challenging to identify clients requiring treatment and those who do not. Specifically, there are no clear criteria for diagnosing complicated grief, which means that sometimes treatment approaches are made based on consensual or personal assessments regarding the distress or impairment level among grievers. 

Besides, the focus on distress intensity and its duration among clients may result in confusion owing to the existence of different models for identifying distress levels. Other factors such as disagreements regarding complicated grief and normal grief in terms of symptoms also confuse assessments. The authors also note the challenges that emerge during therapy concerning the aforementioned risk factors. In particular, some of the risk factors cannot be modified during treatment. However, treatment can focus on modifiable risk factors to enhance its effectiveness. The authors highlight the need for further research regarding risk factors for complicated grief to enhance clarity. 

In chapter 12, Watkins and Mould examine if rumination is constructive or destructive. While noting that depressive rumination is an element of repetitive thought, its maladaptive mechanism prolongs grief responses. They also argue that rumination arises due to discrepancies in progressing towards a specific objective. The discrepancy occurs after a loss such as a bereavement in which people respond to the event through rumination. Such a response is beneficial because it allows the grieving to solve problems, attend to the immediate context, leave unrealistic expectations, and adjust. Thus, rumination is constructive if the individual adjusts positively after the loss or destructive if the distress feelings prolong due to the inability to cope with the loss. 

The authors highlight that rumination affects all people experiencing grief. The differences in responses to grief rely on how well the person adapts over time to avoid distress feelings regarding the loss. Those who recover early experience constructive effects of rumination while those with prolonged distress feelings experience unconstructive effects of rumination. Thus, rumination affects adjustments following a loss in which those who adapt positively process grief concretely while those who are unable to adjust suffer from complicated grief because of thinking continuously about the meaning of the grief. In particular, constructive rumination acts as a coping mechanism for grieving people while unconstructive rumination acts as a hindrance to successful coping and increases suffering. The authors suggest the use of cognitive-behavioral therapy involving rumination for patients with complicated grief to allow clients to process memories related to grief and adjust positively. Clinicians are also advised to educate clients about adaptive rumination to facilitate healing. 

Golden, in chapter 13, explores the idea of autobiographical memory by demonstrating that autobiographical memory entails a mechanism in which people overgeneralize memories based on regularities with different events instead of remembering events. In turn, this complicates grief. Memory is essential because its processing affects numerous aspects of our lives such as goals, personal meanings, and affective states. In particular, it affects the ability to recall positive memories when experiencing distress. In particular, people suffering from severe mental disorders overgeneralize their memories by recalling experiences and comparing different experiences instead of focusing on specific events. The authors relate over-general memory (OGM) to complicated grief by arguing that it delays recovery. Specifically, self-focused rumination is an aspect of OGM bias as it occurs due to negative self-schemata. Besides, OGM bias results in functional avoidance in people suffering from complicated grief by decreasing the ability of the patients from recalling useful memories. The patient generalizes memory recollection to the entire autobiographical memory rather than focusing on a specific recollection. 

OGM bias also impairs executive functioning by compromising the working memory, which reduces the capacity of the working memory and impedes proper retrieval of specific events. The author suggests that when treating complicated grief, clinicians should use approaches that assist clients to access specific memories as this allows the clients to recall positive memories to deal with grief. Other recommended interventions entail memory specific training, mindfulness cognitive therapy, and cognitive behavior therapy. The authors also argue for more research to identify relevant factors related to the autobiographical memory phenomenon and the required treatment approaches. 

Chapter 14,15,16,17 

Mikuliner and Shaver in chapter 14 examine the way the attachment theory developed theoretically and its relation to complicated grief. The authors argue that attachment theory concerns a behavioral system that motivates people to move closer to supportive individuals during needy times. Factors such as reliable and unreliable attachment figures affect the dependent’s development positively and negatively respectively. People also differ in the way their attachment system operates, which results in attachment anxiety and avoidance dimensions. People with secure attachment score low in both dimensions while those with high scores are insecure. Secure people cope with losses or threats positively while insecure ones find it difficult to deal with mental issues. The attachment theory is relevant in complicated grief because when people lose attachment figures, they react with intense distress. In particular, people develop bonds over time through friendship, love, or marriage. When one person dies, the remaining individual undergoes a grieving period characterized by distress and sadness. 

The ability of the person to cope over time relies on the ability to adjust or free themselves from the previous bond through maintaining symbolic bonds with the deceased and establishing new attachment bonds. People with secure attachment can successfully mourn their loved ones and adjust to reality faster. However, people with insecure attachment experience complicated grief owing to their unwillingness or inability to cope with sadness. The defenses and worries related to attachment impede adjustments among insecure people, complicates the grieving process, and result in disorder or chronic mourning. The authors recommend that treating insecure individuals experiencing chronic mourning entail establishing secure attachment with the client before exploring sad experiences. 

In chapter 15, O’Connor examines psychology and neurobiology with a focus on topics such as endocrine, genetics, and magnetic resonance imaging. The author acknowledges the role of attachment theory in complicated grief by focusing on the effect of attachment figures on both mental and physiological regulation. It is noted that two physiological elements are involved when people react to bereavement, namely general stress reaction and attachment-based reaction. The author also identifies different models of complicated grief such as the biopsychological model and the neurobiological model. In particular, the author demonstrates that complicated grief results in physiological alterations such as blood pressure and increased heart rate. Besides, people suffering from complicated grief may sometimes experience severe physiological disorders. Nevertheless, numerous individuals experience alterations in both blood pressure and heart rate during the first several weeks and months after losing someone. They also experience alterations in hormone levels and neuro-transmitters related to stress. These responses also occur when people experience stressful situations unrelated to grief. 

The author also notes that it is challenging to understand the source of the differences when observing people experiencing normal grief and those experiencing complicated grief. The challenges concerns distinguishing reactions from grief and reactions from pre-existing inclination towards physiological disorder that exacerbates due to grief. The author also acknowledges that stakeholders may be compelled to view the grief intensity on a continuum instead of focusing on the time in which grief is diagnosed as a separate disorder or complicated grief. Besides, considering the physiological and neurobiological markers of complicated grief allows stakeholders to differentiate complicated grief from other disorders such as PTSD and depression. 

Boelen, van den Hout, and van den Bout argue for using the cognitive-behavioral approach as a treatment model for complicated grief in chapter 16. While noting the adverse effects and the unique markers of prolonged grief disorder, the authors emphasize the effectiveness of CBT in treating complicated grief. CBT is relevant in complicated grief because clients suffer from problems such as the inability to elaborate and integrate the loss in their autobiographical memory, negative thoughts, and avoidance behaviors related to anxiety and depression. In particular, failure to elaborate and integrate the loss in memory results in continued distress feelings, failure to adjust knowledge regarding self, and persistence of separation distress. The negative thoughts maintain and exacerbate sadness while anxious and depressive avoidance lead to distress, impede patients from elaborating and integrating the loss, and inhibit positive emotions while promoting negative views about the individual and life. All the aforementioned processes are relevant because they influence each other and causes complicated grief symptoms and mediate the effect of different risk factors for the poor outcomes of patients. 

The authors suggest that CBT treats complicated grief by helping the patient integrate current knowledge, identify and alter adverse thought patterns, and replace adverse avoidance effects. Clinicians can focus on interventions such as exposure, cognitive restructuring, and behavioral activation. Exposure interventions help patients elaborate and integrate the loss, cognitive restructuring helps patients identify adverse cognitions and reformulate the cognitions using valid truths, and behavioral activation help patients practice their cognitions. Despite the effectiveness of CBT in treating complicated grief, the authors argue for further research to identify ways of improving CBT by the effect of different treatment elements for specific individuals and clarifying the involved treatment mechanisms. 

In chapter 17, Wagner demonstrates that using approaches such as the internet and computerization for managing complicated grief is innovative and effective. According to the author, the internet has transformed the way mentally ill people interact, communicate, and find support. In particular, grieving people can find social support; remember the lost ones and access treatment. There are social support networks, forums, or discussion groups, grief intervention approaches, and online memorial websites targeting grieving. Online support groups are particularly useful for grieving people who also face stigma or find it challenging to connect in their surroundings. Such platforms encourage social exchange, which enhances a sense of togetherness, improve coping skills, allow geographically distant people to access assistance without hindrances such as first impressions based on physical features. Nevertheless, results regarding the effectiveness of online support groups are inconclusive. The author also examines the effectiveness of traditional interventions focused on treating complicated grief such as CBT, group and individual therapy, preventive approaches, and interventions of high-risk groups and complicated grievers. 

It is demonstrated that the interventions are effective at reducing symptoms. An exploration of internet-based treatments is also conducted in which interventions such as interapy intervention strategy for PTSD are discussed. The approach involves three components including self-confrontation, cognitive reappraisal, and social sharing. However, the author cautions that not all grieving patients benefit from online interventions and the interventions may not assist people with severe sadness, substance use background, psychotic symptoms or suicidal thoughts. Online interventions may also involve self-help approaches, even though their effectiveness is questionable given the need for therapist interaction to decrease symptoms and attrition rates. The author also highlights the benefits and drawbacks of online interventions for grieving while noting the need for further researcher in the field. 

Chapter 18, 19, 20 

Regarding chapter 18, Kissane, Zaider, Li, and Del Gaudio suggest that bereavement does not affect the grieving individual only; it also affects the entire family group. The way people in the family adapt to the loss relies on how well members relate to each other since the family can help people heal or exacerbate the grief intensity. Owing to the interconnected nature of bereavement, the authors recommend the use of family therapy to manage complicated grief as it is useful in alleviating distress. Nevertheless, it is essential to focus on relevant models of family therapy to ensure effectiveness. The authors identify four relevant theoretical models, namely attachment model, cognitive processing model, group adaptation, and pre-existing resilience. The attachment model concerns the relationship aspect of families and the available bonds in which shared loss in the family activates restorative coping. Family therapy facilitates the sharing process. The cognitive processing model concerns understanding the loss using an existing belief system in which members address negative ideas by integrating positive knowledge. In this model, family therapy enhances the adaptability of members. Group adaptation concerns views by different family members to address the grief in which the family therapist facilitates cohesiveness of the family in reaching an agreement. Pre-existing resilience relates to the family strengths such as support networks that ensure resilience in which the role of the family therapists is to affirm those strengths. 

However, it is vital to identify families that require immediate assistance using the Family Relationship Index in addition to considering ethical dilemmas such as conflicting needs of members, confidentiality, in addition to therapy boundaries. The therapy can also be conducted at home. The authors suggest that when treating families for complicated grief, the therapist must focus on aspects such as effective communication and addressing depression. Therapists should also expect challenges such as ensuring precise boundaries, addressing grief based on open discussions, and focusing on the therapy. 

Piper and Ogrodniczuk in chapter 19 also support the use of short-term group therapy for dealing with complicated grief. They highlight the uniqueness of the therapy compared to other interventions by arguing that the therapy focuses on the psychosocial domain rather than pharmacology, and is psychodynamic as it emphasizes aspects such as interpretation, confrontation, clarification, defenses, anxiety, and wishes. The therapy also treats groups rather than individuals, is limited by time, and is patient-centered as the client initiates the discussion. Further, the therapy aims to enable patients to understand the problems concerning their loss to ensure they adapt to the event. There are also two models under the short-term group therapy, including interpretive therapy and supportive therapy. A therapist using the interpretive approach focuses on compelling client expressiveness, identifying painful feelings, interpreting conflicts, subjective impressions, and relevant relationships. 

Using supportive therapy, the focus is on client satisfaction, guidance, problem solving, and the underlying causes of sadness without interpreting. However, the therapy cannot ensure full recovery because it is brief and the treatment may not be effective for all grieving patients. Even though the approach helps a significant number of clients, high relapse rates have been noted. The authors recommend the use of both the supportive and interpretive models in combination to enhance their effectiveness. 

In chapter 20, Rynearson, Schut, and Stroebe argue that governments and relevant organizations must familiarize themselves with the effect of violent death on survivors. In particular, they show that violent death results in extreme difficulties for survivors than in other grieving individuals. The authors attempt to define violent death in which they identify major features of the event such as violence, violation, and volition even though they note that other violent deaths do not demonstrate all the aforementioned features. However, the authors caution against categorizing death because of the way the affected individuals may view the event. In particular, violent death cause extreme sadness among significant others, which can be demonstrated through avoidant thoughts, intrusive thoughts, and post-traumatic stress responses. The uniqueness of violent death such as the involvement of the media, crime, and legal issues result in distinctive effects such as prolonged dysfunction that is related to complicated grief. The authors identify two key syndromes due to violent death, namely separation distress, which can be related to complicated grief and traumatic distress, which can be related to PTSD. 

The authors also explore the relationship between violent death and complicated grief in which they find inadequate research into the prevalence of complicated grief due to violent death, its unique characteristics and risk factors. They also identify several challenges such as the need to establish a complicated grief category due to violent death and suggest that it is essential for the therapist to assess patients generally for complicated grief. The authors also note conceptual issues regarding complicated grief due to violent death. For example, they demonstrate the need to identify the different types of complicated grief due to different causes of death, instruments for assessing complicated grief, and the treatment required to address violent bereavement and their efficacy. The authors conclude by arguing that violent deaths cause unique problems compared to other forms of death and suggest that professional treatments should be offered to decrease the suffering related to the events. 

Final Assignment 

Indeed, people respond to the death of a loved one naturally, even though sadness, loss, and hurt feelings usually arise. Grieving can also entail regret, anger, yearning, and guilt in which people experience the emotions differently. Some people may be confused as they engage in different thoughts while attempting to understand the loss. People also vary in the way they grief in which some can share their feelings comfortably with others while others may deal with the emotions silently through writing or physical exercise. Still, studies have not identified better ways of grieving since each person is unique and copes differently and within a specific period (King & Delgado, 2020). For most people, however, the aforementioned feelings generally fade over time without therapeutic assistance. 

In particular, the period that follows the death of loved one grief varies in its trajectory, nature, and intensity due to different factors. Besides, since death is forever, the state of bereavement also lasts even though the intensity of grief evolves with time for a majority of people who adapt to the death with low-intensity grief. Those who adapt also start living satisfying and meaningful lives without the lost individual. Studies demonstrate that people mourn naturally for six to 12 months in which they experience less intense grief and assimilate the meaning and reality of the loss by returning to their normal lives (King & Delgado, 2020). Such people accept the permanence of death and its outcomes in their lives and revise their plans and goals accordingly. 

However, a significant number of people experience complicated grief in which the feelings do not improve over time. These people continue grieving even after 18 months of the loss in which the intensity of grief for this group can be so high that it interferes with their daily activities (King & Delgado, 2020). People with complicated grief may also depict dysfunctional conduct and experience unfounded thoughts. For example, they might think that the lost individual will come back. Such people suffer from chronic grief disorder that impairs their lives. According to Hollander (2016), among people experiencing bereavement, over 7 percent of them suffer from complicated grief. Consequently, it is important to treat people experiencing complicated grief because of the complications that arise due to prolonged grieving. In particular, numerous complicated grief symptoms can be similar to depression symptoms. In other cases, complicated grief may transform into depression. It is also possible for both complicated grief and depression to occur concurrently, which may worsen the situation. Other people can also suffer from PTSD. Thus, without an intervention, complicated grief can result in several complications such as depression, substance abuse, anxiety, or suicidal thoughts and suicide. In turn, this highlights the importance of treating complicated grief to assist the patients to heal and avoid developing complications. 

It is also worth noting that grieving individuals are sometimes stuck. Nevertheless, being stuck may mean different things for different people. For example, a patient might be stuck in grief because the response to the loss is complicated, which causes them to experience prolonged and persistent grief. Specifically, if the deceased was a vital part of the individual’s life, it may be challenging to deal with grief and it would take time to heal. For example, losing a wife after living together for 40 years may pose problems regarding dealing with the loss especially if your entire identity was focused on being a husband. Nevertheless, if you loved your wife but possessed self-sense, then it might be easier to cope. Therefore, the meaning of death to people also contribute to whether they are stuck or not. Besides, the nature of the death also matters because some losses are sudden, traumatic, or violent. For example, deaths due to suicide pose unique grieving challenges. The shock, blame, guilt, and helplessness that arise can complicate grieving (Currier et al., 2014). Even though we know that we can lose someone someday, which allows us to prepare, this may not contribute to faster grieving. In particular, the grieving process is characterized by conflicting emotions and the reality of losing the emotional attachment and bonding that existed before the death. 

Alternatively, a client may decide to terminate the therapeutic process even after progressing well. Such clients may feel that they have progressed significantly and that they would not want to continue because they cannot have their previous life back. Therefore, being stuck can be an individual choice. For other people, continuous grieving seems beneficial in certain ways as it allows them to forget other issues in their lives. For example, being sad or depressed may attract caring attention from close people who might offer consolation. The cycle can continue endlessly if not discovered and addressed. However, grief is a long process and we might think that people are stuck when in reality they are still grieving. They might be struggling, which may impede their progress but they are not stuck simply because they are not complying with theoretical steps for grief. In particular, some people grieve actively by experiencing the emotions of a loss, which aids in faster healing. Nevertheless, other people grieve passively, which prolongs the grieving process as it takes time to attain complete healing. People undergoing passive grieving may appear to be stuck even though they are dealing with the loss slowly. Some people are stuck because they do not express their feelings about the loss or do not get the opportunity to discuss the loss, which in turn results in prolonged grief that impairs a person’s life. Consequently, grieving people are stuck for different reasons, which should be understood through careful examination. 

I have personally dealt with someone experiencing grief. The experience demonstrated that complicated grief is difficult to understand because the underlying symptoms might be confused with depression or PTSD symptoms. Nevertheless, the disorder impairs every aspect of a person’s life significantly. It leads to poor academic performance, inability to establish useful relationships, avoidance behaviors, extreme anxiety, fear of the unknown, and concerns about the future. Confusion emerges and the grieving individual does not know what to do or where to seek assistance. The person may also think that he can deal with the distress through engaging in other activities even though this may be challenging due to the inability and being overwhelmed by thoughts. The people around also do not understand why the person is behaving that way because they are not familiar with complicated grief and its adverse effects. Therefore, they are unable to offer any assistance. I learnt that a social support network such as friend and family are very useful during the grieving period. In particular, if friends and relatives are familiar with the grief process, they can help the grieving deal with the loss and recover quickly. The more support and love directed towards grieving people, the less time it takes for them to go through the grieving process (Kramer et al., 2011). Besides, if the relatives and friends value the importance of mourning, can discuss the loss, and help actively, then it will be easier to heal. However, if relatives or friends do not understand the importance of mourning and compel the grieving to forget the loss, adverse emotions may persist and the grieving becomes helpless, lonely, and sad, which exacerbates the grief process. 

It can also be difficult to cope if you are dealing with personal, health, and financial problems since it will take time to heal and the experience will be painful. Besides, stereotypes such as the belief that men should not cry constrain the grieving process by increasing its complexity. The ability and willingness to demonstrate your loss to others, connect with people around, and discuss the loss openly reduce the pain and the time it takes to grieve (Kramer et al., 2011). Nevertheless, avoiding others, being lonely, and avoiding discussing the loss or seeking help makes it hard to deal with the loss. Generally, grief is a challenging feeling and it is difficult to address the feelings of sadness and loss in many cases individually. Connecting with family and friends who are aware of the grief process is essential because it contributes to faster healing. Social support is essential to healing. Friends and family can offer financial and emotional assistance to assist the vulnerable while mourning as a group facilitates the healing process. 

The biggest takeaway from the course is that complicated grief affects health and well-being adversely. However, while researchers have recommended various treatment options, it is unclear which of them is appropriate for patients. Challenges such as the diversity of the symptoms, lack of a clear conceptualization of the disorder, lack of specific diagnostic criteria, and the different ways in which the disorder affects different people persist. It will be essential in the future to properly assess patients suffering from complicated grief to identify those requiring treatment. It will also be important to identify people at a high risk of developing complicated grief to facilitate early interventions. Nevertheless, identifying those at risk might be challenging owing to the nature of death because sometimes it occurs unexpectedly. Thus, it is necessary to be trained properly about the disorder and evidence-based treatment options to intervene in patients seeking assistance. 

Besides, proposals about integrating complicated grief into DSM still face obstacles due to the aforementioned challenges (Shear et al., 2011), which hampers the formulation of precise treatment approaches. In particular, there are still disagreements regarding diagnosing complicated grief due to issues such as cultural differences in the experience of grief and issues related to the difference between normal and complicated grief. I believe that the difficulty of conceptualizing complicated grief does not matter if the affected people access and obtain the required treatment and assistance. In situations in which a person is, experiencing relentless and extreme grief that impairs his or her daily life but lack a mental diagnosis, then clinicians cannot continue debating about the required actions. They must treat the person for complicated grief. 

As the stakeholders continue debating, clinicians should understand the risk factors and attributes of the disorder and find proven ways of helping clients such as strengthening client support systems, offering counseling, or encouraging clients to find support groups (Kramer et al., 2011). It is also essential to use reliable and valid assessment instruments when assessing complicated grief. Additionally, since complicated grief involves the loss of someone in the community, therapists should collaborate with different stakeholders such as family members, friends, and the community when assisting patients to ensure that they understand the importance of addressing the disorder. It is worth noting that while many people grieve, only a few experience complicated grief over a long period without observable changes. The few people require assistance to resolve the issues they are facing, which highlights the role of treatment. Besides, while grief can be considered a natural and normal process, it can become complicated. Nevertheless, stakeholders and researchers disagree regarding the diagnosis, nature, and prevalence of complicated grief. It will be useful to recognize complicated grief as a separate disorder in the future to facilitate the formulation of appropriate management approaches. 


Currier, J. M., Irish, J. E. F., Neimeyer, R. A., & Foster, J. D. (2014). Attachment, Continuing Bonds, and Complicated Grief Following Violent Loss: Testing a Moderated Model. Death Studies , 39 (4), 201–210. https://doi.org/10.1080/07481187.2014.975869 

Hollander, T. (2016). Ambiguous Loss and Complicated Grief: Understanding the Grief of Parents of the Disappeared in Northern Uganda. Journal of Family Theory & Review , 8 (3), 294–307. https://doi.org/10.1111/jftr.12153 

King, K. M., & Delgado, H. (2020). Losing a Family Member to Incarceration: Grief and Resilience. Journal of Loss and Trauma , 1–15. https://doi.org/10.1080/15325024.2020.1816753 

Kramer, B. J., Kavanaugh, M., Trentham-Dietz, A., Walsh, M., & Yonker, J. A. (2011). Complicated Grief Symptoms in Caregivers of Persons with Lung Cancer: The Role of Family Conflict, Intrapsychic Strains, and Hospice Utilization. OMEGA - Journal of Death and Dying , 62 (3), 201–220. https://doi.org/10.2190/om.62.3.a 

Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., Reynolds, C., Lebowitz, B., Sung, S., Ghesquiere, A., Gorscak, B., Clayton, P., Ito, M., Nakajima, S., Konishi, T., Melhem, N., Meert, K., Schiff, M., O’Connor, M.-F., & First, M. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety , 28 (2), 103–117. https://doi.org/10.1002/da.20780 

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