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08 February, 2016

When grief gets complicated, what can we do?

There is no right way to grieve. Each of us will be bereaved at some stage and none of us can avoid this pain for ever. Responding to our loss is a very individual subjective experience and it deserves respect. It is not easy to grieve but this loss is part of living.

The work of Elizabeth Kubler-Ross is often referenced as a description of typical bereavement, but her seminal identification of the stages of grief has been widely misunderstood. It is true that Denial, Anger, Bargaining, Depression and Acceptance may be seen at some time in the aftermath of loss, but there is no normal or right process of grieving. There is no sequence that necessarily applies to everyone, and these are not “stages” in a timed sense. Kubler-Ross did not intend to imply her “stages” should be followed in a serial pattern and they were never meant to indicate a right way to grieve. 

On the subject of suffering and loss my patients have been my best teachers. Invaluable lessons about bereavement have come from their witness. Their experience has taught me that grief is not something only pondered in the abstract or defined in books. It is a personal lived-in experience and that is why the bereaved have so many lessons for us, whoever we are, whether we grieved in the past, are still grieving or have yet to grieve in the future.
Jack became a widower nearly two years ago, when his wife and partner of nearly thirty years died suddenly, tragically and painfully. I asked him recently what he would want people to know about his grief and this is what he told me. “Everyone needs to know one thing above all else: things do get better, in time the pain genuinely gets less and even terrible pain becomes more bearable than it was at its height. In time the road ahead becomes much clearer”. This message of hope is the single most important lesson we can learn about grief. But what happens when this recovery from grief is delayed or jeopardised? This is an experience we refer to as “complicated grief”. This is a grief which has become stuck or into which new feelings of hopelessness, despair or even suicidality have become attached. In complicated grief the pain is much slower to ease and the preoccupation with loss deepens. Instead of a gradual recovery and steady re-engagement with life and relationships (the journey most people can expect in time) those with complicated grief remain unable to consider life without their loved one. Their pain remains at a heightened level. Complicated grief is better understood in terms of the bereaved experience rather than by its timing. Complicated grief is not just longer than it might have been, it is also more morbid, more preoccupied, isolated and hopeless. 
Exceptional bereavements make complicated grief more likely. The loss of a child is probably the hardest experience for any adult to bear and bereavement through Suicide or violent crime is also severely stressful. Inconceivable irreconcilable ambivalent and unjust departures from this life are immensely more difficult for those left behind. In these circumstances it may be unreasonable to expect someone to “accept” their loss and so more relative recovery goals may be all that can be anticipated, at least for a time.  
Complicated grief is exacerbated by bitterness and disputes. The cynics used to say “wherever there is a death there is a family, and wherever there is a will there is a row”. When a funeral is blighted by the settling of old scores or the division of the mourners into the worthy and the unworthy it is the living who continue to suffer, not the dead.
Even complicated grief can be mitigated by kindness. The bereaved often appreciate the support of friends and family. For others the sanctuary of time alone is invaluable, but either way the bereaved have an experience that is individual, personal and highly sensitive. It may be that it helps to cling to one another. Others prefer to stand alone. If you are bereaved and you have social support then my best advice is go to it. If faith and religious practice is part of your life then return to it. Most of all, be kind to yourself. Take practical steps. It helps to anticipate difficult anniversaries, the first Christmas, the Birthdays, the empty chair at the dinner table. It is worth taking time to think ahead and making plans for these especially challenging grieving times. Seek solace from trusted friends but avoid destructive or illusory comforts. Dismiss those who tell you how to do this or that. Remember there is no single right way to mourn.
The poet Thomas Lynch wrote memorably about grief in his “Life studies from the Dismal Trade: The Undertaking”. His book is a celebrated account of his life and experiences as an undertaker “burying the dead” in a small town in Michigan USA.  Lynch helps us to consider the changing culture and language of our modern negotiation with death and dying. In Ireland the culture is also changing and it is impossible to be sure what it will become, but to date life in Ireland has been particularly rich with regard to respect for the dying and the dead. 
Still there is arguably an increasing tendency to distance ourselves from the physical reality of death. Perhaps there is a tendency to sanitise death and this may in itself be a kind of denial. People speak now of “passing” or “passing on” as though the words death and dying have become less socially acceptable. These shifts may be indicative. Compared to our parents and our grandparents generations we are far less likely to have kept a dead person in our house for any time or even less likely in our youth to have seen a dead body laid out. Every day we hear that we are living longer, as though we can expect to live forever, but we are dying no less frequently. The rituals of the wake and of the removal are less certain than ever before, and when we bury our dead, we do so now in graveyards that are no longer marked with headstones pointing towards the heavens. Now if we bury our dead their gravestones are laid flat to facilitate the mowing of the lawns.  
This may all be necessary and right but truthful acknowledgement of death is never something to be feared. Being able to speak the truth about death actually sets us free and helps us to live life mindfully in what Jon Kabat Zinn has called “full catastrophic reality”. Being mindful about our brief lives also requires us to be mindful of our proximal death. This cognitive reality allows us prepare for the real world and to recover more readily when we are bereaved. As Thomas Lynch puts it “The only way around it, is through it”. Nobody should be expected just to “move on” from bereavement. Even when grief is complicated we can only learn to move through the experience of grief and so to move with it thought our lives. Most bereaved people would agree. The bereaved never forget, but even the most complicated bereavement can be followed by the re-discovery of life and hope once more.
If you would like to have more information and support about the issues raised in this blog or if you need information and support about any mental health issue than please call our helpline on (01) 249 3333. There are useful links about this subject on several websites such as  HELPGUIDE.ORG: Coping with Grief and Loss or the Health Service Executive South Regional Suicide Resource Office website 
The books referenced here include Thomas Lynch “The Undertaking : Life studies from the dismal trade” and Elizabeth Kubler-Ross “On death and dying : What the dying have to teach doctors nurses, clergy and their own families" These are available in most good book shops. The work of Jon Kabat Zinn is referenced in many publications on mindfulness for example  “Mindfulness : A practical guide to peace in a frantic world” by Penman and Williams and this is also widely available.

Tags:   Grief   Bereavement  


Prof Jim Lucey

Prof. Jim Lucey was Medical Director of St Patrick’s Mental Health Services, Dublin, from 2008 to 2019. He is Clinical Professor of Psychiatry at Trinity College Dublin. He has been working for more than 30 years with patients suffering from mental health problems. In addition to medical management, he maintains his clinical practice at St Patrick`s, where he specialises in the assessment, diagnosis and management of Obsessive Compulsive Disorder (OCD) and other anxiety disorders. He gives public lectures and is a regular broadcaster on mental health matters on RTÉ radio, featuring on ‘Today with Sean O’Rourke’.