Complicated Grief after multiple losses, now cut off from the world…

Dear Dr. Neimeyer,

As a director of a bereavement center myself, I am very concerned about a friend. Her mother died about 4 years ago. Her father died about 8 months ago. Then, her son, as far as we know, died of an accidental overdose about one month after her father. The truth is it seems she never quite was able to adjust after the death of her mother. She was a devoted daughter to her parents. The following information comes to me by a mutual friend.

Since her son’s death she has become completely cut off from the world. She does not drive or leave the house. She is completely terrified of doing anything. I’m told she does not turn on the TV, listen to music, answer the phone. She does not pick up a pencil.

I believe there is a housekeeper in the home making sure she eats. Her husband and surviving children are fed up with her state of mind. Apparently they were told that anything they do for her would be enabling her situation. So they do nothing to help her. I’m told she has a psychiatrist who has her on medication. Our mutual friend, who is also a therapist, believes that she has become numb to her situation, her family and the world.

My experience with her over the years is that she was always a somewhat fearful and cautious person. Any suggestions made to her are met with resistance. We are at a loss for how to help.

Karen

Dear Karen,

First, I applaud and appreciate your engagement with your friend’s sad retreat from life, which seems to have exhausted her family’s patience and resources, and perhaps that of her professional caregivers as well. So let me join you here in offering a few ideas that you might bring to her, and perhaps her family, as you jointly seek a way to begin re-engaging your friend in life after far too many deaths in quick succession.

To begin, it is important to acknowledge the profound challenge to your friend’s sense of attachment occasioned by the death of her mother, followed by that of her father a few years later. As you describe, she was a loving and devoted daughter, likely receiving and then giving care in her relation to her parents across a lifetime. Especially when our bonds are close in this way, their severance through death often thrusts us into a very vulnerable place, which in her case was almost unspeakably compounded by the intentional or unintentional death of her son just a month following that of her father. Cut off nearly simultaneously from the last of two parents who had long nurtured her and a child who she had long nurtured, it is not surprising that she collapsed into a a wounded self-isolation over these four years.

What, then, might be done about this? The profundity of your friend’s apparent grief and its intractability over time certainly suggests that it qualifies as prolonged grief disorder, a serious complication in bereavement that is moving toward global recognition in the World Health Organization’s ICD-11. Although this or any other diagnosis would require confirmation by a qualified mental health professional, this condition, known more commonly as complicated grief, typically requires specialized intervention beyond that provided by caring family, bereavement support groups, or even generalists in professions such as psychology, social work or psychiatry. Antidepressant medication could make a contribution to your friend’s treatment by mitigating symptoms of sleep disruption, anhedonia, impaired concentration, and so on, but evidence clearly indicates that this alone is insufficient to address the profound separation distress that complicated grief represents. Instead, a specialized form of complicated grief treatment, like that developed by Katherine Shear and her colleagues at Columbia University, represents the state of the art approach to intervention, one that is being disseminated to a large and growing cohort of therapists around the country, and indeed around the world. Investigating whether there are trained practitioners in your friend’s region of the country could therefore be a helpful step.

In addition to this attachment-informed approach to treatment, a trauma-informed approach could also be relevant, as the loss of your friend’s son in particular could present unique challenges associated with the circumstances under which he died. Here again Shear’s complicated grief treatment offers critically helpful “revisiting” procedures for helping clients integrate the hard reality of the story of dying without experiential avoidance, which can be extended by attention to the many questions that ambiguous losses and suicide deaths typically pose. When orchestrated by a trained practitioner, such interventions can encourage and prompt relevant forms of social support by family, friends and perhaps mutual support groups, optimally helping your friend adapt to three cardinal losses without compounding them with further relational estrangement in her ongoing life.

Dr. Neimeyer