Complicated Grief: When Loss Doesn’t Let Go

It had been four years since her husband died. Her daughter, carefully, mentioned that she’d turned down every invitation for the past two years, that she still couldn’t pass a grocery store he’d liked without driving around the block, that she was still keeping his side of the closet exactly as he’d left it. Her mother looked at her with something between exhaustion and bewilderment and said she didn’t understand what else she was supposed to feel. She wasn’t pretending. She genuinely didn’t know that grief could freeze.

For most people who experience a significant loss, grief follows a path that is deeply painful but also, over time, gradually moving. The acute anguish of early loss doesn’t vanish. But it shifts. The person begins, slowly and unevenly, to find some accommodation with the new reality. They can think about the person who died without being completely undone. They reconnect with life, with relationships, with possibilities. This doesn’t mean they love the person less or that they’ve forgotten. It means they’ve found a way to carry the loss forward rather than being stopped by it.

For some people, this movement doesn’t happen. They remain in the acute phase of grief for months and years. The loss doesn’t soften. It stays fresh, raw, and consuming, as if it just happened. This is complicated grief, now more formally called Prolonged Grief Disorder in the DSM-5-TR.

What Prolonged Grief Disorder Is

Prolonged Grief Disorder was added to the DSM-5-TR in 2022, giving formal diagnostic recognition to a clinical reality that grief researchers had identified decades earlier. The diagnosis requires that at least twelve months have passed since the death (six months for children), and that the person is experiencing intense yearning or longing for the deceased, along with at least three of the following eight Criterion B symptoms: intense emotional pain, marked disbelief about the death, difficulty accepting the death, feeling that life is meaningless without the person, emotional numbness, difficulty engaging with social activities or interests, avoidance of reminders of the deceased, feeling that part of oneself has died, and bitterness or anger about the loss. (A licensed clinician uses the full DSM-5-TR criteria, which should be consulted for a formal assessment.)

These symptoms must be causing significant impairment in daily functioning and must not be better explained by another mental health condition. The grief must be out of proportion with expected cultural or religious norms.

Estimates suggest that about 7 to 10 percent of bereaved individuals develop Prolonged Grief Disorder, though rates are higher following certain kinds of loss, including sudden or traumatic death, suicide loss, and the loss of a child.

Why Some Grief Gets Stuck

Grief researchers have identified several factors that increase the risk of complicated or prolonged grief.

The nature of the relationship to the deceased matters enormously. Relationships characterized by extreme closeness or dependence, in which the person’s identity was significantly organized around the relationship, carry higher risk. So do relationships that were ambivalent, conflicted, or unresolved, where the death forecloses the possibility of resolution that the grieving person was still hoping for.

The circumstances of the death matter. Sudden, unexpected, traumatic, or violent death significantly increases risk. When death is traumatic, the trauma itself can complicate the grief process: the person can’t think about the deceased without being flooded by traumatic intrusions. Processing the loss requires working through the trauma first, which requires specialized treatment.

Suicide loss is particularly associated with complicated grief. The specific shock, confusion, guilt, and stigma of suicide loss create conditions that are harder to navigate than most other losses.

Lack of social support is a consistent risk factor. Grief that has to be carried largely alone is more likely to become complicated. This is one reason that culturally and socially isolated bereaved people are at elevated risk.

Prior losses, prior mental health history, and a history of insecure attachment patterns all increase vulnerability. A person whose early relationships taught them that connection is dangerous, or that losses cannot be survived, may respond to significant loss with a level of intensity that reflects accumulated rather than only current experience.

What It Feels Like

People with complicated grief often describe feeling as if time has not passed since the death. They may look at the calendar and know intellectually that years have gone by, but the felt experience of the loss remains as immediate as it was in the first weeks.

Avoidance is common: avoiding reminders of the person, places they frequented, people who knew them, or conversely, being unable to move or alter anything associated with the deceased. Both extremes can represent efforts to manage an overwhelming grief that hasn’t found a way forward.

There is often a sense that life cannot be meaningful without the person who died, that the future the grieving person had imagined is so completely foreclosed that no alternative future seems worth pursuing. This isn’t the same as depression’s global hopelessness, though it can coexist with depression. It’s more specifically an inability to imagine a life organized differently than the one that was interrupted.

Intense anger, guilt, and “what if” thinking are common. People replay the events around the death, looking for the moment when things could have gone differently. For suicide loss survivors especially, this can become a consuming and destabilizing preoccupation.

Treatment That Works

The good news is that Prolonged Grief Disorder responds to treatment. Complicated Grief Treatment (CGT), developed by researchers at Columbia University, is the best-studied specific intervention and has shown strong results in clinical trials. It integrates elements of exposure therapy, interpersonal therapy, and motivational techniques to help people move through the grief they’ve been unable to process.

CGT addresses both the loss itself and the restoration of engagement with life. It includes exercises that encourage retelling the story of the death and the relationship, working through the painful aspects that have been avoided, while also actively building toward what life going forward could look like. It’s not about forgetting or moving on in the dismissive sense of that phrase. It’s about being able to hold the loss without it holding you immobile.

Cognitive-behavioral therapies adapted for grief, as well as EMDR for cases where traumatic bereavement is present, have also shown effectiveness. Regular grief support groups are beneficial for many people though not sufficient for those meeting criteria for Prolonged Grief Disorder.

If you recognize yourself in this description, if the acute pain of loss has not shifted over a long period and has been preventing you from reengaging with your own life, what you’re experiencing has a name and it has treatment. Grief is supposed to be painful. It isn’t supposed to be permanent.

This article is for educational purposes only and is not a substitute for professional mental health treatment. If you are experiencing a mental health crisis, please reach out to a qualified mental health provider or call 988.