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What is Complicated Grief?

images In order to understand what complicated grief is, it is important to understand what “normal grief” is and the four tasks a grieving person should address in order to adapt to the loss. According to a book published by Worden in 2009, Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner the four tasks a grieving person should address are:


  1. Accept the Loss
  2. Process the Pain of Grief
  3. Adjust without the Deceased
  4. Live effectively in the world by finding a place for the deceased in your emotional life. 

In the first task, “Accept the Loss,” the mourner should face reality that the death happened and the person will not come back. Some people however refuse to believe that the death happened causing them to be in denial thus getting stuck in this first task. In the second task, “Process the Pain of Grief,” the person needs to acknowledge and work through their pain. If they do not, then they will carry the pain with them throughout their lives and the pain can manifest into physical symptoms. In “Adjusting without the Deceased,” three areas of adjustment needs to be addressed: external, internal and spiritual adjustment. External adjustment usually develops around 3 to 4 months after the loss and involves coming to terms with being alone and having to adjust to the different roles played by the deceased. This could mean that the person takes on the role of being the bread winner, the accountant, gardener, mother, father, etc. In internal adjustment, it is important for the person to adjust to their own sense of self. In other words, how the death has affected their self efficacy. For the mourner, it is important to address “Who am I now?” Spiritual adjustment simply means the adjustment one has to the world. Searching for meaning and its life changes in order to make sense and regain control of their life. The last task is to “Live effectively in the world by finding a place for the deceased in your emotional life.” This means that the mourner should find ways to remember the deceased without it getting in the way of continuing one’s life. The grief counselor’s role in this task is to help the mourner find a place for the dead in their emotional lives that will enable them to go on living effectively in the world.

Complicated mourning has been given many different labels. Unresolved grief, chronic grief, or delayed grief are some of the names given to describe complicated grief. Whatever name you choose, complicated grief as described by Worden is when a “person is overwhelmed, resorts to maladaptive behavior, or remains interminably in the state of grief without progression of the mourning process towards completion.”  Something is impeding the mourning process and a good adaptation to the loss is negatively affected. This table below proposed by Katherine Shear, Naomi Simon, Melanie Wall, et al in a study they published in 2011 in New York shows a set of diagnostic criteria which is strong enough to produce continuing separation distress. In other words, the symptoms presented must be associated with impairment, similar to other psychiatric diagnosis.

 It is important to mention however, that research on complicated grief is ongoing. Many believe that standard diagnosis is needed to research some of the symptoms of complicated grief. I believe that it is more important to provide comfort and support to the mourner rather than to introduce another diagnostic category. More research however is needed to make a proper diagnosis.

Symptom domain


Separation distress

The patient has ≥1 of the following 4 symptoms: 

1) Persistent, intense yearning or longing for the deceased 

2) Frequent feelings of intense loneliness or emptiness 

3) Recurrent negative thoughts about life without the deceased or recurrent urge to join the deceased 

4) Preoccupying thoughts about the deceased that impair daily functioning


The patient has ≥2 of the following 8 symptoms: 

1) Rumination about circumstances of the death 

2) Frequent disbelief or inability to accept the death


3) Persistent feeling of being shocked, stunned, or emotionally numb since the death 

4) Recurrent feelings of anger or bitterness regarding the death 

5) Difficulty trusting or caring about others since the loss 

6) Experiencing pain or other somatic symptoms the deceased person had, hearing the voice of the deceased, or seeing the deceased person 

7) Intense emotional reactions to memories of the deceased


8) Excessive avoidance or excessive preoccupation with places, people, and things related to the deceased or death

Grief is a condition that we will all experience. Therapists job is to diagnose and treat mental and emotional disorders.Therapists need to take a closer look when working with clients because some of these disorders may be intertwined with grief. I believe that it is important for counselors to pay close attention to what their clients are discussing in session as well as what their presenting symptoms are because there may be other complications other than the ones they are coming in for. I also think that counselors must educate themselves in grief counseling in order to recognize and give proper treatment to their clients.



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What is Complicated Grief?

Helen Nieves

Helen Nieves is a Licensed Mental Health Counselor and Certified Attention Deficit Consultant Specialist. She teaches ADHD on line and is on the Advisory Board at The American Institute of Health Care Professionals. She also received advanced training in Rational Emotive Behavior Therapy and in Grief Counseling.

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APA Reference
Nieves, H. (2015). What is Complicated Grief?. Psych Central. Retrieved on October 29, 2020, from


Last updated: 16 Apr 2015
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