Complicated Grief: An Evolving Theoretical Landscape

The loss of a loved one through death is a ubiquitous human experience that is associated with heightened psychological and physical distress on the part of the survivor (Shear et al., 2011; Stroebe, Schut, & Stroebe, 2007). For most individuals, grief symptoms attenuate naturally over a period of time (Shear et al., 2011); however, a subset of bereaved adults struggles to adapt to their loss, experiencing what is known as complicated grief (CG; Prigerson et al., 2009; Shear et al., 2011). CG, also known as prolonged grief disorder (Prigerson et al., 2009) or persistent complex bereavement disorder (PCBD; American Psychiatric Association [APA], 2013), is a protracted, debilitating, sometimes life-threatening grief response that is prevalent in approximately 10% to 15% of bereaved individuals (Shear et al., 2011), with recent studies reporting much higher rates (e.g., 31% to 70%; McDevitt-Murphy, Neimeyer, Burke, Williams, & Lawson, 2012; Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004; Momartin, Silove, Manicavasagar, & Steel, 2004; Shear, Jackson, Essock, Donahue, & Felton, 2006). In contrast to adaptive grief, CG is characterized by intensified grief symptoms that fail to diminish naturally within 6 months postloss, resulting in clinically significant psychological and physical distress, as well as impairment in occupational and social functioning (Lannen, Wolfe, Prigerson, Onelov, & Kreicbergs, 2008; Shear et al., 2011). CG is associated with many deleterious psychological outcomes, such as suicidal ideation and behavior (Szanto et al., 2006), sleep disturbance (Maytal et al., 2007), disruption in daily activities (Monk, Houck, & Shear, 2006), and increased substance use (Prigerson et al., 2009). CG may also be linked to the development of other mental disorders (e.g., CG is associated with heightened panic and suicidality among individuals with bipolar disorder; Simon et al., 2005). Although most bereaved individuals are able to adapt to loss without professional support, research has suggested that treatment is indicated for individuals with CG (Currier, Neimeyer, & Berman, 2008). However, with the exception of a brief review of contemporary bereavement research (Howarth, 2011), discussion of CG in the counseling literature is scarce, providing counselors with little guidance for distinguishing between common grief and CG. The purpose of this article is to provide counselors with an overview of CG for clinical utility in identifying and treating this serious, problematic grief response. Specifically, the current article presents an overview of CG and provides approaches for its assessment and treatment. Definitions and Key Terms Although often used interchangeably, bereavement, grief, and mourning are distinct constructs. Bereavement is the state of having lost a significant person through death (Shear, 2012). Mourning refers to the public expressions of grief, demonstrated through various rituals and customs that vary by society or cultural group (Stroebe, Hansson, Schut, & Stroebe, 2008). Grief is the complex psychological response to bereavement, comprising feelings, thoughts, and behaviors related to the loss (Shear, 2012). Acute grief is the distressing initial response to loss, during which the griever may experience shock, disbelief, anguish, sadness, fear, and separation distress, among other reactions (Simon, 2013; Zisook & Shear, 2009), the intensity and duration of which fall on a continuum that ranges from uncomplicated grief to CG (Holland, Neimeyer, Boelen, & Prigerson, 2009; Horowitz et al., 1993). Although Kubler-Ross's (1969) stage theory has shaped popular thinking on grief, contemporary empirical research has generated an evolution of thought on grief from a linear, uniform process to an idiosyncratic experience that can vary considerably between individuals in terms of symptom type, intensity, and duration. Acute grief is not only a period of preoccupation with distressing thoughts and feelings associated with the loss, but also a period in which the griever faces the reality of the loss and rebuilds his or her life (Stroebe & Schut, 1999). …