Posts tagged “Complicated Grief”

What is “healthy” grief?

When it comes to mental health there are few hard and fast rules, and grief is no different. Between differing genetics and life experience, no two people are exactly alike, and so we each grieve in a unique way. This may be a difficult idea to digest – after all, humans are literally wired to categorize (“good” & “bad,” “safe” & “unsafe”) and we tend to bring this same heuristic to grief (“healthy” & “unhealthy,” “over it” vs. “still affected”). I encourage you, though, to take a less heavy-handed view. An individual’s history (their genetics and life experience) determines how grief occurs, not some pre-determined list of “should’s.”

So rather than prescriptions, I will share what I have found to be some useful ideas about grief. First are two ideas that I’ve already written about: the stages of grief is largely myth and the risk-factors that increase the chance someone will have a complicated course of grief. The two I will write about here focus on grief over time.


The first is William Worden’s “Four Tasks of Mourning.” Like the stages, these are not linear steps.  Instead, they are abstract processes. When talking with someone about their experience of grief I might be wondering: How much time and attention have they given each of these steps? How much are each of these tasks sources of distress, or sources of comfort, for them? The four tasks are:

  • To Accept the Reality of the Loss
  • To Work Through the Pain of Grief
  • To Adjust to an Environment in Which the Deceased is Missing
  • To Find an Enduring Connection With the Deceased While Embarking on a New Life

The second idea is Margaret Stroebe and Hank Schut’s “Dual Process Model.” While the content may look familiar, unlike the previous two, this model has no list of stages. Instead, it highlights two types of activities:

  •  Loss – activities that are directly related to grief. These may include thinking about the person who has died and/or experiencing a range of emotions
  •  Restoration – activities that represent adapting to the loss. These may include developing new activities that the loss requires (i.e. finding companionship in others, if the deceased was the primary companion).

The “Dual Process Model” posits that in “healthy” grief, people oscillate back and forth between “loss” and “restoration” activities. That is, in the morning someone may be crying in bed (loss) while later that afternoon that same person may be applying for a new job (restoration). The time period surrounding the oscillation (i.e. loss to restoration in one day in this example) varies by person and circumstances, but the general idea is that the more flexibly someone can oscillate between loss and restoration throughout their daily life, the better they will feel.

With all that said, “completing” the Four Tasks of Mourning or “becoming flexible” at shifting between loss and restoration activities does not necessarily mean “healthy” grief. It may, but in my experience, individual factors are just as (if not more) important than any of these ideas.

Interested in learning more about the possible benefits of individualized grief counseling? Give me a call at 720-515-9427.

Grief Counseling Effectiveness Depends On Your Interest

A quick Google search might indicate that grief counseling is not very effective. This well publicized idea, though, is incomplete and harmful.

The caution against grief counseling is a benevolent one.  It is based in the well-established finding that many people don’t need professional help to effectively work through their grief.  However, this warning stigmatizes the minority (which, mind you, is still a large number of people!) who do in fact need help.  Let me explain:


  •  10-20% of people who experience a death loss develop what’s called complicated grief. All of the same research that cautions against grief counseling explicitly recommends grief counseling for people with complicated grief.  I would go one step further and recommend grief counseling to a person at risk for complicated grief.  You can read more about complicated grief here.
  • Most studies actively recruit their participants. This method distorts findings because research includes many people who never would have sought grief counseling on their own. This contrasts with my experience: nearly every client I work with has sought me out. It turns out this is a key difference! A less well publicized review found that grief counseling is effective for people who self-select to receive treatment (Effectiveness of Grief Therapy: A Meta-Analaysis, Allumbaugh & Hoyt, 1999).  So if you’re considering grief counseling, your mere interest will improve its ability to help you.

I could say much more about research on the effectiveness of grief counseling, but to be brief I will stop here.  Grief is ultimately an individual process, and a difficult one (like most psychological phenomena) to understand. If you’d like to talk through whether grief counseling would help you, give me a call at 720-515-9427.

Do Unemotional Grievers Need Counseling?

Some people appear unaffected by grief. Their life quickly returns to normal and they don’t seem to be upset following a death. Many well-meaning people, including therapists, might interpret this as repressed grief. These caring people fear that there will be a significant cost (substance abuse, withdrawal from others, disconnection from themselves, etc.) to avoiding emotions. Many times there can be, but sometimes this concern is misguided. Consider a few more factors before you tell a seemingly unaffected person to seek out grief counseling:

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  • How did they adapt to past losses? Past behavior is one of the best predictors of future behavior. If they previously experienced a major death or loss of relationship, consider how that went. If well, they will likely benefit from following the same steps (i.e. exercising regularly, talking about it vs. not talking about it, etc.). If it went poorly, they will likely benefit from trying something new like counseling.
  • How emotionally expressive are they normally? People who are typically unemotional will likely continue to appear unemotional, even in the face of catastrophe. Sometimes appearing unemotional is, and has always been, a maladaptive coping mechanism for a sensitive person who has never learned how to communicate their feelings (this person is likely to benefit from counseling). But don’t forget to imagine that it might just be their normal, well-adjusted temperament to be unemotional.  It does not have to be an indication that something is wrong.
  • Do they want to go to grief counseling? This question isn’t always so obvious. Have you asked? Can you respect their autonomy if the answer is no? Careful: forcing or guilt-tripping someone into counseling can actually make them get worse. Can you be patient if they don’t want to talk about it? How about providing some education about the impact of complicated grief (see my other post) if they aren’t sure?

Want some expert help assessing whether you, or someone you care about, would benefit from grief counseling? Give me a call at 720-515-9427 and let’s sort it out.

When Facing Death, Words Can Do a Lot.

In this podcast, Dr. Ira Byock highlights the importance of healing old relational wounds.  I am excited to share this because many of the people I see for grief counseling would be in far less pain today had they had the opportunity to have these sorts of conversations with their loved ones.  While still very possible, it's much harder to reconcile old wounds when the other person is no longer here.  Should you have the opportunity now, consider your future grief and don't wait.


Dr. Byock advises four statements that can guide these conversations.  I think they can also be a useful way of understanding about what grieving people need to reconcile before they can move forward following a death.

  • Please forgive me
  • I forgive you
  • Thank you
  • I love you

Listen to this fantastic podcast, or give me a call 720-515-9427 if you would like help mending or clarifying your relationships before you or a loved one dies.

The Importance of Planning

We’re bad at talking about death. And yet, whether or not it’s conscious, most people have fairly specific wishes for how they want to die.

  • Some prefer to die at home surrounded by family members whereas others prefer to die in a hospital to reduce the burden family members might feel
  • Some prefer to know that their doctors will fight aggressively to the very end whereas others prefer more emphasis on the quality of their life once they have come to terms with what might be a low chance of recovery
  • Some prefer making specific plans around finances or what a memorial service might look like whereas others might be less concerned with specifics than having their values considered when decisions are made

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The most important step, though, is to have the conversation because the alternative can be disastrous. When people don’t talk about end of life wishes, patients often get what they don’t want and family members often end up burdened with the worst consequences. A well-intending family member might have no idea whether or not his or her loved one would have wanted to be put on a ventilator, or even worse, know when a ventilator should be turned off. They might feel guilty for the decision they do make; they might regret not having clarified things much earlier; And I’ve seen time and time again that not having these conversations can disrupt a family member’s grieving process, causing unnecessary harm for months or years following the death.

Many people prefer not to talk about death secretly hoping that if they ignore it, it will go away. Others imagine that these conversations can wait. But I’ve learned a simple mantra over and over again from my, sometimes intensely suffering, clients: Don’t wait. Find a way to at least begin talking about the most important conversation most of us never have.

Looking for places to start? I can be a resource, or you may want to start with these fantastic websites:

Complicated Grief: Definition, Impact, & Risk Factors

In the wake of a death, people experience grief. They may feel sad, lonely, or low on energy. They may feel disconnected from others and think frequently about the person who has died. This can go on for months or even years, but as long as the intensity of their symptoms decreases over time, their experience is most likely healthy and normal. The trouble occurs when time alone does not heal; in some cases these acute symptoms morph into a persistent condition called complicated grief. People experiencing complicated grief get "stuck." That is, they are unable to effectively move on with their lives.

In spite of affecting ten to twenty percent of people who experience a significant loss, complicated grief is a little known mental health condition. This is all the more surprising when its impact is understood: People who develop complicated grief tend to be debilitated by it. They may look severely depressed or traumatized. They may have difficulty connecting to others or keeping a job and are at greater risk for developing a substance use disorder.


Someone with complicated grief can benefit from psychotherapy. Also someone who appears high risk for developing complicated grief in the future can benefit from psychotherapy as a means of prevention, even before the death. Psychological risk factors for complicated grief include: already having a significant history of close people dying, a history of coping through suppression (i.e., trying to force stressful thoughts out of your mind rather than facing them), having a significant mental health history, or simply being very close to the person who died (e.g., the loving spouse). If you or someone you care about might be at risk for, or is already showing signs of complicated grief, speaking with a trained mental health provider could be of real help.

Learn more about preventing and treating complicated grief by contacting Dr. Altschuh at 720-515-9427 or visit