Prolonged Grief

What does that look like? Rumination and guilt remain at the forefront for many months or years. (“I should have visited more”, “I didn’t get her to the hospital in time”, “They wouldn’t have caught Covid if we didn’t go to that event.”) Intense yearning is the new center of life. Activities are severely curtailed to avoid reminders. A sense of identity is snatched with no hope to rebuild. The pain is persistent, invasive and upends normal functioning. Other themes can include protest of the loss, constantly imagining other outcomes, denial, shame, self-blame and survivor’s guilt.

This early rumination serves a purpose. It keeps the brain busy with guilt or focus on activating details (family conflicts about the death or estate, disputes after the fact about hospital care) so we do not have to consider the landscape ahead without this person. When looked at subjectively, it’s understandable. When there is an attachment severance, the brain must rewire. But on the path to adaptive grief, this discombobulation eventually evens out, and we begin to slowly accept the reality of a new life. When it stays intense and our lives begin to shut down, this is cause for concern.

Who is most vulnerable to prolonged grief disorder? Someone with an early attachment loss is particularly susceptible to prolonged grief. The previous attachment trauma acts like the agar of a petri dish where disordered grief can flourish.

The Real Stages of Grief

In the earliest stage of loss, or acute grief, we may experience all these feelings for a while. Confusion, sleep disturbances, seeking reminders such as looking at pictures, sleeping on their side of the bed or smelling the loved one’s clothes are all very common. Adaptive loss begins by accepting the reality of our new, albeit unwanted, life. It’s an erratic process. Grief will be in the background of life but focus on work or seeing friends is possible during this phase. Special days or unexpected moments can still cause the pain of the loss to swell. So having sad moments where we tear up or feel down around the holidays, even years after, does not mean you are not in adaptive grief. Adaptive grief is when we accept the finality of loss and reconfigure our relationship to the loved one after they have died. (An unexpected loss such as the death of a child or a violent death might progress differently and by their inherent nature, pose another possible risk for PGD.)

Conversely, in prolonged grief disorder the preoccupation with the death remains for a year or longer. It feels the same as acute grief, but it does not move over time. The central marker is its impact on daily function. A timeline of a year for PGD was assigned as to provide standardization within the Diagnostic and Statistical Manual (DSM-5-TR) which is a professional guide that provides the requirements to diagnose or name a disorder. (It’s six months in the ICD-10, the International Classification of Disease) This is not meant to stigmatize or pathologize grief. Grief is normal. Instead, a diagnosis is used to help with providing long-term professional support like the ability to be reimbursed for insurance claims. It also distinguishes PGD from other disorders to tailor appropriate care. For example, PDG is not depression. Depression often feels like “free floating sadness” or lack of interest or enjoyment. PGD clients care very much and are preoccupied with the death. Still, depression and PGD can co-occur. Having had depression before the death increases the odds.

For PGD, Lake Austin Psychotherapy offers a highly effective, evidence-based treatment designed by The Center for Complicated Grief at Columbia University. Contact us for your free assessment to see if what you are experiencing meets the criteria for specialized grief support. We also offer support for generalized grief both in the immediate or even decades after the death.

Grief Over Time—and When to Worry

Grief is normal and enduring but is problematic if it becomes stuck in an activating phase for a very long period. Here are some potential blocking thoughts to notice that may indicate PGD if they are experienced for some time.

(From Dr. Katherine Shear, the Founding Director of the Center for Complicated Grief at Columbia.)

• Feeling hurt, alone and as if no one could help

• Avoidance of reminders

• Persistent anger over the unfairness of the loss

• Lack of faith you will ever recover from the loss

• “If only” thinking where you avoid the death

• Survivor’s guilt that you could never enjoy life without this person/beloved pet

• That you did not do enough

Signs that Grief is Becoming Adaptive

Dr. Kathy Shear devised these grief H.E.A.L.I.N.G. milestones to help identify ways to move towards adapting to loss:

• Honor your loved one and self by discovering own interest and values

• Ease emotional pain by opening yourself to both painful and pleasant emotions. Trust the pain will not control you

• Accept grief and let it find a place in your life

• Learn to live with reminders of your loss

• Integrate memories of your loved ones. Share about them so you can enjoy and learn from them

• Narrate stories of the death for yourself and others

• Gather others around you for support

How Can Therapy Help?

Whether you are in the earlier stages of your loss or feeling “stuck” many months or years later, therapy can help facilitate movement to a place of acceptance that is bearable. Even in adaptive stages of loss, having a place to share the pain without judgment can be helpful, especially during activating times like the holidays. At Lake Austin Psychotherapy, we provide a free virtual therapy session to plan for your care. Click here to schedule.