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About complicated grief
Losing a loved one or friend requires a period of adjustment, during which people grieve for the loss and re-establish their lives without the loved one’s presence. For most people, the intensity of their grief recedes with time as they adjust to life without their loved one.
For some people, however, this normal grieving and healing process can become derailed such that they develop a chronic and debilitating condition. In this Advice Book, the term complicated grief will be used to refer to this condition, although it is sometimes referred to as prolonged grief or bereavement related disorder (or traumatic bereavement depending on the manner of death). For clinicians using DSM5, the diagnosis 'persistent complex bereavement disorder' has been described, with explicit criteria, in conditions for further study - Section III. Some indications that the normal grieving process has been derailed, and that complicated grief may be present, include:
- preoccupation with the deceased or circumstances of the death
- persistent yearning or longing for the deceased
- difficulty making sense of the loss
- misinterpretation of aspects of the loss (e.g., excessive self-blame)
- avoidance of reminders of the loss
- feeling that life is meaningless without the deceased
- prolonged experience of grief, e.g., for more than one year
Complicated grief is associated with more prolonged distress and disability, as well as greater negative health outcomes and suicidality, than normal grief. It is important to note that complicated grief is distinct from anxiety and depression, although there are some common features across these disorders.
Approximately one in ten bereaved people experience complicated grief, with higher rates amongst those bereaved by disaster or violent death, or parents who lose a child (Shear et al., 2011).
Complicated grief reactions have traditionally been diagnosed as depression, PTSD, or an anxiety disorder. However, there is now substantial evidence to suggest that, despite some similarities and frequent comorbidity, complicated grief is distinct from these other disorders. For example, veterans suffering any post-bereavement disorder are likely to report ongoing sadness. Those experiencing complicated grief, however, are less likely to report depressive symptoms such as low mood and feelings of hopelessness, or anxiety symptoms such as restlessness or nervousness. Instead, prominent features will include preoccupation (e.g., intense yearning for the deceased, rumination about the death), reactive distress (e.g., anger, self-blame, avoidance of reminders), and identity disruption (e.g., a sense that life is futile or meaningless, detachment from others).
It is important to recognise complicated grief, as interventions only targeting anxiety, depression, or PTSD are not usually effective. Careful assessment of symptoms is therefore required. Post-bereavement anxiety, depression, or PTSD (either independent of, or comorbid with, complicated grief) can be treated using standard approaches for these disorders.
Screening and assessment
Veterans presenting with persistent and severe symptoms following the death of a close friend or relative should be assessed for the possible presence of complicated grief. In most cases, a detailed diagnostic interview is the best way to proceed, although several scales are available (e.g., the Texas Revised Inventory of Grief (Faschingbauer, 1981), the Hogan Grief Reaction Checklist (Hogan, Greenfield, & Schmidt, 2001), the Grief Evaluation Measure (Jordan et al., 2005), and the Inventory of Complicated Grief – Revised (Prigerson et al., 1995)). Complicated grief can be a significant risk factor for suicide, as veterans may feel that life is meaningless, or express a wish to die in order to be reunited with the deceased. It is therefore important to ask grieving veterans about suicidal ideation using direct and unambiguous questions such as:
- Are there times when things seem so bad that you think about killing yourself?
- Do you have a plan of how you might do this?
- Do you have access to … (check means and opportunity)?
- Have you ever harmed yourself or tried to kill yourself in the past?
- Do you live alone (or unsupervised)?
- Do you use amphetamines, alcohol, or other substances?
It is also important to consider and address other risk factor such as social isolation and substance abuse.
Most people who experience grief find that, with the support of their family, friends and usual coping strategies, their grief resolves over time and no professional help is needed. The box below contains information on self-management strategies that may be useful for veterans who have experienced loss.
Psychoeducation and self-management strategies
Health care providers can offer advice on basic self-management strategies that the veteran can use to assist in recovery from grief (or while undergoing any necessary psychological and/or pharmacological interventions for complicated grief). Encourage the veteran to:
- Prioritise spending time and reconnecting with their social supports, e.g., sympathetic family members and friends, local interpersonal community activities.
- Maintain (or re-establish) their daily routine and current roles (e.g., work, family). This is particularly important for veterans who have a lot of unstructured time. This may include starting an exercise routine (as simple as a daily 20 minute walk) and engaging in planned pleasant events.
- Reduce substance use. While alcohol and drugs may alleviate distress in the short term, they inhibit recovery.
Cognitive behavioural therapy
Mental health practitioner delivered cognitive behavioural therapy (CBT) should be considered for veterans with complicated grief (Wittouck et al., 2011). Whilst CBT has some general techniques applicable across a range of disorders, specific CBT techniques for targeting complicated grief are:
- Cognitive therapy – This assists veterans to identify unhelpful thinking patterns relating to their loss and to revise the way they think about those aspects. This can be particularly useful for veterans who are experiencing guilt-related thoughts and intrusive memories.
- Behavioural techniques – Techniques such as activity scheduling can assist the veteran to re-engage with the world, undertake positive or pleasurable activities, and set goals for the future.
- Exposure therapy – This approach can be particularly useful for those whose loss occurred in traumatic circumstances and experience fear-based intrusive memories. Imaginal exposure involves repeatedly telling the story of the loss. In vivo exposure may involve confronting places or people associated with the loss that the veteran has been avoiding. Where the veteran did not witness the death, and their intrusive image is based on their worst fear of what the death may have involved, there may be benefit in first trying to clarify the known details and then seeking to address or correct any misinformation or assumptions that this image may be based on. Such clarifications can potentially address the intrusive images without the requirement to engage in imaginal exposure.
- The intervention can also include having imagined conversations with the deceased, evoking happy memories, and exploring regrets and resentment so that they are able to make goals for the future.
Psychological treatment setting and duration
Complicated grief can be treated in an outpatient setting and does not usually require admission to a psychiatric hospital unit. There is not sufficient evidence to determine a recommended treatment length for complicated grief; however, as whenever using CBT, it is important to establish a clear treatment plan for each time-limited episode of care.
Veterans with milder forms of complicated grief will usually respond well to psychological interventions alone. Psychological interventions are also the treatment of choice for veterans with more severe symptoms; however, evidence suggests an adjunctive course of newer antidepressants can help veterans tolerate grief-focused CBT.
Referral and coordinated care
- VVCS - Veterans and Veterans Families Counselling Service (VVCS): This service provides veterans and their families with counselling and group programs Australia-wide. VVCS can be contacted 24 hours on 1800 011 046. (www.vvcs.gov.au)
- Psychiatrist: for specialist management of more severe, chronic or complex problems. Some psychiatrists specialise in psychological treatments; they can review or prescribe medication, provide diagnoses, and manage co-occurring physical health problems. Allied health providers should liaise with GPs to arrange a referral. GPs can access a list of private psychiatrists at http://www.ranzcp.org/Resources/find-a-psychiatrist.aspx.
- A treatment plan should be developed collaboratively with the veteran and their family, and coordinated across service providers.
- Consider psychosocial and/or vocational rehabilitation services from the beginning of treatment. DVA can offer extensive rehabilitation services for entitled veterans (www.dva.gov.au/rehabilitation).
- Veterans Line (1800 011 046) can be reached 24 hours a day across Australia for crisis support and counselling. This service is provided by VVCS.
- The At Ease portal (www.at-ease.dva.gov.au) contains mental health and wellbeing resources, including websites, mobile apps and information booklets for both veterans and clinicians.
- The Australian Centre for Grief and Bereavement (www.grief.org.au) provides some useful information on grief for clients. The Centre for Complicated Grief (www.complicatedgrief.org) is a US resource for people experiencing complicated grief.
This Advice Book has the following resources in the appendices that may be useful for veterans who are experiencing symptoms of complicated grief:
- further explanation of CBT elements (Appendix B)
- psychoeducation handout for veteran and general psychoeducation script outline (Appendix D & Appendix L)
- self-monitoring sheets including a daily activity schedule (Appendix E)
- pleasant events schedule (Appendix F)
- information on where veterans can get more help, e.g., Veterans Line, DVA funded psychological and rehabilitation services (Appendix J).