Caroline was a tall, elegant woman in her late forties, dressed in black from head to toe.* Moments after we met for the first time, she broke down in tears, revealing between sobs the news that her husband, Jim, was dead. She emptied her purse in front of me, showing me that she always carried her husband’s wallet, his wedding ring, and the gold chain he used to wear. Caroline’s sense of loss was fresh and palpable, as if she was newly bereaved and barely holding together.
Loren Soeiro, Ph.D. ABPP is a psychologist in private practice in New York City, specializing in helping people find peace, fulfillment, and success in their relationships and their work. He is board-certified as an expert in clinical psychology by the American Board of Professional Psychology. Previously, he worked as an attending psychologist and assistant professor of clinical psychiatry at Montefiore Medical Center, where many of his private patients were training physicians, surgeons, and others with high-intensity careers.
Editor: Nadeem Noor
It took me the better part of our evaluation to discover that Jim had died more than seven years earlier.
Caroline wasn’t wearing black to make a fashion statement; she was still in the grip of mourning, drowning in feelings that had overwhelmed her from the moment Jim had died. Every time she thought about her husband, she experienced his death just as she had when she’d heard the news for the first time — which involved not only sadness and loss, but also quite a lot of anger.
Caroline was furious with Jim for leaving her — for giving up on their life together and allowing himself to die, she said. Much of her present-day life was structured around constant references to this loss. At home, Caroline told me, she had set up what amounted to a shrine to Jim — one corner of her bedroom, crowded with happy photos of the two of them together. She watched their wedding video almost every night. Under her bed, she kept the clothes he’d been wearing when he was admitted to the hospital for the last time. She described Jim as utterly devoted to her, in life, just as she seemed to be devoting her widowhood to his death.
My patient was suffering what’s known today as persistent complex bereavementdisorder, which in the past has been referred to as complicated grief or traumatic grief, and is experienced by about seven percent of people who suffer a major loss. Complex bereavement differs from what’s come to be seen as “normal” grief in its severity, and also on a neurological level: Brain scans of those suffering complicated grief differ from most of the recently bereaved. This type of grief is not equivalent to clinical depression; a grieving person may also be depressed, but antidepressant medications generally don’t alleviate the symptoms of complex bereavement. It presents clinically as something between normal grief and PTSD, because it refreshes itself daily, circling relentlessly around a sudden loss with no hint of mitigation. Sufferers are overburdened with yearning for their lost loved one, unable to accept that he or she is gone.
Traumatic grief doesn’t necessarily mean that the death in question has occurred in the course of a traumatic event, although sudden, unexpected deaths are more likely to lead to it. Rather, some people may experience complex bereavement because they are more susceptible to it than others. Currently it’s believed that ambivalent attachment to or dependency on the deceased person, or insecure attachment to caregivers in childhood, can result in a complex bereavement response. Similarly, low self-esteem, low trust in others, and a lack of supportive family members can be contributing factors as well.
Complicated bereavement can feel life-encompassing, as it was for my patient. Caroline had relied on Jim for almost everything, from making her breakfast in the morning to doing her laundry, to driving her around town for appointments. After her husband’s death, Caroline felt as if she could no longer care for herself. She didn’t work; she couldn’t drive; she didn’t know how to cook; she wasn’t comfortable maintaining her own home. Jim’s death left her with the feeling that she could never master all of life’s minutiae on her own. As a widow, she felt assaulted by new obligations and responsibilities, uncertain if she’d ever be capable of living alone.
Normally, adaptation to a loss takes place naturally. People in mourning need to work through the story of their relationship with their loved ones, including its unhappy end — such that the grief reaction diminishes over time, replaced with generally positive (if bittersweet) memories, and balanced by a renewed sense of participation in life. With most bereaved patients in psychotherapy, the ability to laugh and smile while talking through positive memories about the deceased predicts the reduction of grief symptomatology over time.
Complicated grief treatment builds on these natural processes to help the patient become “unstuck” and to change his or her focus from death to life again. It focuses on processing the events of the loss in detail, and simultaneously on reorienting the patient toward the more pleasurable aspects of living. With therapeutic assistance, the mourner can be brought carefully through the stages of normal mourning toward a place where the deceased is represented in memory in a fuller, more complex way, so that the individual is ultimately seen as more than just a loss.
In treating Caroline’s grief, it was necessary to facilitate some insight, as well. Caroline had relied on Jim for her every contact with the outside world; with respect to her husband, she had behaved much like a child. Although she loved being cared for and catered to by Jim, after his death she began to realize she had also resented the way he had infantilized her — and the way she had allowed it to happen. Caroline eventually came to feel as if her anger at her husband was actually the misdirected expression of her failure to take command of her own life. Over time, she was able to see Jim’s death not only as a loss, but also a provocation — a difficult but worthwhile challenge, demanding that she re-engage with the world as a fully independent adult. As she made this transition, bit by bit, her memories of Jim became less idealized and more realistic. Caroline developed a new perspective on her husband, seeing him as a flawed but lovable human being — even as she grew to see herself in a more balanced way as well.