Prolonged Grief vs. Normal Grief

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In March 2022, a new diagnosis was added to the DSM-V, which is the handbook used by mental health providers and researchers to describe and classify groups of symptoms. Technically, this categorizes “prolonged grief” as a “disorder.” (APA, 2022)

Many clinicians have strongly objected to this classification, claiming that it pathologizes grief. Isn’t grief basic to being human, after all? Who has not felt the profound loss of a loved one, whether a family member, friend, or a beloved pet? Why is it being considered a disorder?

As a clinician who has seen firsthand how much suffering prolonged grief can create, I disagree with the objections and support treating prolonged grief as a disorder. An example of prolonged grief may be helpful here:

John and Amelia lost an adult daughter to an overdose five years ago. They had both been aware of her dangerous use of substances but had disagreed as to how to respond. Amelia was constantly trying to reach out to their daughter, sometimes rescuing her from her own consequences of bad decisions. John held firm to a more “tough love” approach. Both were devastated by the tragic loss when she died. Amelia could not accept that her daughter was gone and continued to speak of her as though she were still living, even trying to invite her to holiday events at their home three years after the death. John finally convinced her to seek grief counseling with him.

There are two questions that I’d ask the reader to consider:

1. In what ways is this new diagnosis going to help the people whose grief persists at an intense level year after year?
2. Why shouldn’t grief be taken as seriously as other mental health struggles such as anxiety, depression, or OCD? Each of these disorders is described in the DSM-V. Rather than worry about stigmatizing grief, wouldn’t our efforts be better spent on de-stigmatizing mental health disorders?

How will this new diagnosis be helpful?

Prolonged grief is different from normal grief and identifying it as a distinct problem allows for intensely grieving people to receive treatment tailored to their needs.

Prolonged grief is not the same as normal grief. There are differences in time, intensity, and effect upon daily functioning. Normal grief slowly fades with time, making it possible to move on with life while accepting the loss as real and important. A large majority of people are able to resume some normalcy in their lives at a point between six months and two years after the loss of a loved one. Periods of sadness might reoccur at certain times or even daily beyond the two-year point, but it is not experienced as a constant yearning or longing for the deceased (US Urns online, 2022).

Grief is considered to be “prolonged” when the bereaved is having severe symptoms which interfere with their daily life more than a year after the loss. These symptoms might be based in a refusal to accept the death, such as setting a place for the deceased at a dining table, or keeping their clothing as if the items are still needed by the deceased. Sometimes, the longing to be with the deceased is so strong that it leads to suicidal thoughts. Others experience a persistent emptiness or numbness which doesn’t let up years after the death. It is estimated that almost 10% of grievers have severe symptoms beyond the one-year point, leaving them feeling stuck and miserable. (NIH, 2017)

~James came to therapy for help with depressed mood, anxiety, and dissatisfaction with his marriage. It eventually became clear that James was feeling intense grief at the loss of his younger brother to a sudden illness when they were both children. He felt irrational guilt for not having “protected his little brother” although there was nothing that he could have done to prevent the death. Feelings of intense sadness, emptiness, and longing for his brother had only become heavier with time.

Treatment programs for prolonged grief are available to help those who seek help in overcoming their intense sadness and longing. One such treatment program was developed at Columbia University and has been more effective for grievers than psychotherapy directed specifically at depression symptoms. It is a 16-week program that involves some of the same techniques that help victims of trauma.

Why shouldn’t intense and persistent grief be understood as a mental health problem?

While grief is a normal reaction to loss, prolonged grief isn’t statistically normal. As noted earlier, only about 10% of the population of grievers experience prolonged grief. It is a mental health issue for those individuals who suffer year after year without any relief of their sadness. Our efforts would be better spent on de-stigmatizing all mental health problems, rather than fearing to identify those problems which require help.

Final thoughts

While there are no rules about how long grief should last, there are some general guidelines of what to expect when a loved one is lost. For some grievers, maybe due to particular circumstances or additional challenges happening at the same time as the loss, grief does not fade with time but in fact becomes worse. If you are among those who have continued to suffer relentlessly from a loss that occurred at least one year ago, you might find comfort in knowing that there is help for you. Resources available include the Association for Death Education and Counseling, The Columbia Center for Complicated Grief, and The National Foundation for Grieving Children, Teens, and Families.

Grief Essential Reads

Conversations With Patients Who Have Died

We Heal From Grief in Relationship

To find a therapist, please visit the Psychology Today Therapy Directory.