Note:  This Integrative Whole Health tool focuses on grief related to a death loss.  A focus on other types of losses is beyond the scope of “Coping with Grief” and related tools, although you may find this tool helpful when working with a patient who has experienced a loss other than death. 

Deviations from “typical” (i.e., acute) grief that require more aggressive intervention were described as early as 1944.¹  In complicated grief, symptoms are long-lasting and may intensify over time; the person has trouble accepting the death and resuming life.  Something is getting in the way of the grief process and not allowing the person to adequately adapt to the loss.²  Some bereaved individuals who experience complicated grief do not recognize that their behavior and symptoms are related to a previous loss.²

More attention has been focused on complicated grief recently.  Estimates of the prevalence of complicated grief vary widely, based on circumstances and relationship with the deceased.  An estimate published in 2011 indicates that 2%-7% of those bereaved in the general public experience complicated grief.³  Prevalence is high among Veterans, a group at risk for disenfranchised (hidden) grief.  Literature notes that complicated grief is critically under recognized and unaddressed in Servicemembers.⁴  

A study of 114 Vietnam-era combat Veterans admitted to a PTSD inpatient rehabilitation unit identified that 70% scored higher (i.e., worse) on standardized measures of grief symptoms related to friends lost in combat 30 years previous, than did spouses who were bereaved in the past six months.⁵  Two studies of Servicemembers and Veterans who served after September 11, 2001, revealed that about 80% had experienced the death of someone important to them and almost one-third (31.25% and 30.3%) of those bereaved met criteria for complicated grief.^6,7  One study involved those seeking care for combat-related PTSD, the other group was receiving outpatient mental health care.  In the PTSD group, complicated grief was more prevalent among Veterans who lost a fellow Servicemember than in those who lost someone close who was not a Servicemember, and it was associated with significantly greater PTSD severity, functional impairment, trauma-related guilt, and lifetime suicide attempts.  In the group receiving outpatient mental health care, rates of complicated grief were the same whether the loss was a fellow Servicemember, family member, or friend, and it was associated with worse PTSD, depression, anxiety, stress, and poorer quality of life above and beyond PTSD.