The faithful pastor knows that the funeral is not the end of grief, but just the beginning. Love, compassion, sympathy, reassurance that tears are always acceptable, ample opportunities to share stories of their loved one, special sensitivity around holidays and anniversaries, the delicate balance between added congregational support and intrusiveness, involvement in memorials and other activities which prompt remembering, and of course the practical care of widows (and widowers) whose families are unable or unavailable to provide that care.[1] These are pastoral responses to grief which normally, in combination with the ministry of the Word, the sacraments, prayer, and the fellowship of God's people, will foster hope and help the grieving person get through that first year. It is never easy.

As a pastor you will see raw emotions come to the surface from time to time. The grieving person will need to share stories, sometimes over and over again. Particularly the person will repeatedly share the story of how the loved one died. It is appropriate for the pastor to inquire about this periodically in order to facilitate this repetition. Each time the pastor will gently encourage the grieving person to see God's love and provision reflected in that story. The observant pastor will also notice that the grieving person is beginning to adjust to the world around them.

One day the grieving person will tell his or her pastor about cleaning out his or her loved one's closet or drawers, giving away the clothing, or changing the room which is most associated with the deceased. These are telltale signs that the person has emotionally relocated the deceased and is preparing to move on with life.[2]

Normally, the work of grief will occur over the course of a year or two. When it's over, those who have processed their grief will feel a sense of relief and closure. However, a variety of factors in the life of the person who is grieving, in his or her relationship with the deceased, or in the event that precipitated grief can create complicated grief, which will not resolve on its own, even with good support from a caring pastor. In this article, we will look at complicated grief, the factors which are likely to produce it, and an appropriate pastoral response.

Complicated Grief

The definition of complicated grief is often drawn from Horowitz, Wilner, Marmar, and Krupnick.[3] "Pathological grief is 'the intensification of grief to the level where the person is overwhelmed, resorts to maladaptive behavior, or remains interminably in the state of grief without progression of the mourning process towards completion.' ... [It] involves processes that do not move progressively toward assimilation or accommodation but, instead, lead to stereotyped repetitions or extensive interruptions of healing." The literature on this subject has several labels which are used for complicated grief: pathological grief, complicated bereavement[4], abnormal grief (or grieving), unresolved grief. Surveys suggest that between 10 and 15 percent of all grieving might be categorized appropriately as complicated grief.[5]

William Worden identifies four types of complicated grief.[6] (1) A chronic grief which continues on without stopping and never comes to a satisfactory conclusion. (2) Delayed grief in which the normal grieving process is suppressed or limited at the time of loss and then resurfaces later with far greater emotional intensity. (3) Exaggerated grief in which the person feels completely overwhelmed with grief and resorts to behavior which makes his or her situation worse.[7] (4) Masked grief, similar to exaggerated grief, but here the person is not aware of the loss (or losses) lying behind the symptoms.

Bev set her table for two every afternoon and then became angry when her husband didn't come home. Jim couldn't come home. He had died several months earlier in a tragic accident.

It had been a snowy January morning which had deposited more than a foot of new snow and made local roads very slick. Bev remembered helping Jim shovel the driveway even before the snowplow had passed down their road. He was determined to make it into work that morning, a trip of about five miles. Bev kissed him goodbye as he climbed into his pickup. She then went inside and called her office to let them know she would not try to come in to work (which would have been a trip of nearly twenty miles). She lay down to rest for a while. She was awakened by the phone. The local sheriff told her there had been an accident and that he would stop by in a few minutes to take her to the hospital. She knew the sheriff and found it strange that he was coming to get her. She remembers offering up a prayer that Jim would be okay.

Bev didn't remember seeing the pickup off the road, even though they had to drive right by it. Jim was in the operating room when she arrived, and they wouldn't let her in. Later the doctor came and said something to her. She was finally allowed into the room where Jim seemed to be sleeping peacefully.

The church where they were members had a new pastor. His funeral service was very formal, right out of the book. Bev has no memory of ever talking with the pastor about the service or about Jim's death. (She stopped attending church services after this and never saw that pastor again.) She felt that she had to be strong for the children. Jim's family had come up from the South, and she found herself spending most of her time providing hospitality.

On one level, Bev knew that Jim had died in that accident. On another level, it never quite registered. During the days that followed, Bev threw herself back into her work. Many mentioned how well she was taking it. But in the evening the chair on the other side of the table was empty, and she wondered if Jim was taking another "company trip," or worse that he was seeing someone else.

Sleeping became a major problem. After about a month, this caused her life to begin to fall apart. She remembers pulling the sheets off the bed one night and jumping on them, screaming, "If you're not going to sleep, then you're not going to have a bed to sleep in!" The screaming actually worked, once she calmed down she slept several hours that night.

Her work began to suffer, and her mother became concerned enough to take her to a doctor. He gave her twelve pills and sent her home. "Twelve pills! What good was that going to do?" She took her twelve pills and threw them as hard as she could onto the floor. The sleepless nights persisted, and her work continued to decline.

Finally her supervisor placed her on administrative leave and told her to go get some counseling. Her mother took her to another doctor. At least this one listened. He set her up with a grief counselor and an antidepressant.

I met Beverly some twenty-five years later, serving as the hospice chaplain for her sister and mother. They died just a month apart. Being aware of some of Bev's story, I provided an extra measure of pastoral support for Bev, helping her to reconnect with her local church (under a new and far more pastoral minister). We spent time in prayer and in the Word, and for the first time Bev was able to tell the complete story. One day I stopped by at her request for a bereavement visit. When I arrived she had a book in her hands, the guest book from Jim's funeral. For the first time in twenty-five years she read through the names of those who were present, verbally introducing me to each person and sharing stories about them and about Jim. The short visit became a long one and was filled with many tears. Tears that were twenty-five years late, but better late than never.

Now Bev continues with her church. She has taken up clogging and dances with a local group at country fairs and nursing homes and the like. She has a life again. And at last report, she sleeps well at night.

This is complicated grief. It does not often resolve, and certainly not in any short time frame. For those who suffer with it, it touches every aspect of their lives.

Signs of Complicated Grief

There are some signs of complicated grief that we should look for as pastors.[8]

• continued irritability with outbursts of violent rage;
• deep feelings of guilt, regret, and a significant decline in personal self-image;
• suicidal thoughts or plans to act upon the thoughts;
• severe and increasing inability to concentrate, to learn new information, or to remember previously known information;
• self-destructive behaviors;
• radical and sudden changes of lifestyle, often shocking to the family: relocating one's home, changing jobs, dropping out of school, ending significant relationships, etc.;
• the development of physical symptoms which imitate those of the deceased.

Bev's lack of normal grief emotions around the time of the funeral, her denial of the death of her husband (acted out at the supper table), her inability to sleep, and her inability to perform the basic tasks of her job were all signs that the grieving process was not following a normal course. In the early days following a significant loss these signs could easily be mistaken for acute but normal grief. However, after several months had gone by with a clearly negative trajectory, they became the markers of her descent into the darkness of complicated grief.

In general, the pastor should be concerned if the grieving person, over time, is becoming increasingly emotional or has shown no emotion, if grief lasts for a long time (usually in excess of two years), or if the person becomes increasingly dysfunctional as time goes by. Pastors are not trained to diagnose complicated grief or to distinguish it from various physical ailments. A pastor who suspects complicated grief should refer the grieving parishioner to a medical professional to ensure that there are no physical causes for these symptoms and to make a referral to a professional grief therapist if this is appropriate.

Factors which Contribute to Complicated Grief

There are various factors which may predispose a person to complicated grief.[9]

Some are personal:

• a personal inability to express emotions;
• a history of depression or other mental disorders;
• a history of past complicated grief reactions.

Some are social:

• a loss that is stigmatized by society (suicide, AIDS, substance abuse, abortion, criminal activity on the part of the deceased, etc.);
• grief in a person whom society does not view as an appropriate mourner (a gay partner, the elderly, a roommate, a convict, the homeless, etc.);
• or grief that is expressed through personal isolation or withdrawal from others.

Some are relational:

• strong ambivalence in the relationship between the mourner and the deceased;
• over-dependency in the relationship on the part of either person;
• abuse in the relationship.

But the strongest predictor of complicated grief is the nature of the loss itself:

• sudden, unexpected death;
• violent, mutilating death or murder;
• suicide;
• multiple losses in a short period of time;
• catastrophic disaster;
• death that is viewed as having been preventable;
• where the grieving person was a witness to violent death;
• where the grieving person played some role in the cause of death;
• where no body or other convincing evidence of death was found;
• where the grieving person was not informed of the death or was prevented from attending the death-associated rituals (funeral, memorial service, burial, etc.);
• death of a child;
• death after a prolonged illness.

Not everyone who experiences one of these factors will develop complicated grief. In fact most will not, but all are at risk. A pastor involved with a family that experiences any of these should be aware of the potential for complicated grief.

A Pastoral Response to Complicated Grief

A devout Christian couple experienced the crushing loss of late term miscarriage. The pastor offered to do a funeral service since the unborn infant had been named and joyously anticipated by the couple, their friends and family, and even by the congregation. The couple was uncertain, and the decision was made to hold a memorial after a regular worship service and to invite others present to share their own similar experiences.

After worship that morning the pastor announced their intentions and invited any who wanted to participate to stay. The memorial began soon after and continued for hours. Dozens of women shared their experience of miscarriages, and the pain and grief they still felt many years later. In many cases, these women had never told anyone other than their immediate family about the pregnancy. The couple was well supported, and many reported how healing they found the service.

Sometimes I wonder how different Beverly's life might have been if the pastor who did Jim's funeral had taken the time to provide real pastoral care for Bev and her family. If he had met with Bev and the family, gently encouraged them to share their stories about Jim and about the tragedy of his death, the process of normal grieving might have begun. If he had focused on Bev, making sure that she was emotionally and spiritual supported, even as she sought to care for others, perhaps the complications which would carry this grief on for more than twenty-five years could have been averted. If he and the church had followed up on her absence from worship, a significant change in her lifestyle, at least she would have had support as she walked through the dark valley of complicated grief.

Pastors cannot do it all. Complicated grief often requires the intervention of medical professionals, trained grief counselors, and professionally facilitated support groups. Yet in times past, churches and communities provided the additional support needed to see people through the kinds of grief and loss that do not easily resolve. Pastors may not be trained grief therapists, but we can and should listen for the themes of loss and intense pain which characterize complicated grief. If the person can't even speak the name of the deceased without intense and fresh grief, if even minor events trigger strong grief reactions, if the mourner can't remove the deceased's shoes from the living room months after the loss, if he or she complains of symptoms similar to those of the deceased, or if he or she shows a sudden change of behavior or lifestyle, then the pastor needs to focus more attention, more time, and more compassion toward that grieving individual.[10]

A person experiencing complicated grief should be seen by his or her medical doctor to rule out physical problems. If the person talks with you about suicidal thoughts or intentions, you may be required by state law to report this to the appropriate authorities.[11] As a pastor, you can also help people to recognize their loss, express their feelings, and even encourage them to begin the task of saying good-bye. You can listen to their stories with compassion and explore with them how God and his grace fits into these stories. You can visit the graveside with them. You can give the widow permission to sell her deceased husband's old Ford pickup, or give the widower permission to replace the old broken stove on which his deceased wife cooked so many meals.

Listening without demanding.

Revisiting without pushing.

Weeping with them when they weep, and laughing when they laugh.

Inviting them to make use of a local support group, or even offering to go with them for the first time.

Reassurances concerning the resurrection and the continued unfailing love of God can make a world of difference for those who are grieving. It takes only a few moments to offer a gentle reminder of grace and of the goodness of our God: "The Father of mercies and the God of all comfort, who comforts us in all our affliction, so that we may be able to comfort those who are in any affliction, with the comfort with which we ourselves are comforted by God" (2 Cor. 1:3-4). This kind of pastoral response can be a healthy preventative or the beginning of healing for complicated grief.

Endnotes

[1] I hardly need to mention the numerous biblical admonitions to provide care for the widow (cf. Deut. 10:18, 26:12-13; Psalm 68:5; 146:9; Acts 6:1; 1 Tim. 5:3-5, 16; James 1:27). In our modern society an elderly widower may find himself in the same situation envisioned in Scripture, requiring church response. Help with transportation, household responsibilities, health care needs, even financial support may be biblically mandated for all the elderly who are bereaved among us today.

[2] J. William Worden, Grief Counseling & Grief Therapy, 2nd ed. (New York: Springer, 1991), 16.

[3] Ibid., 70, quoting M.J. Horowitz, N. Wilner, C. Marmar, & J. Krupnick, "Pathological Grief and the Activation of Latent Self Images," American Journal of Psychiatry 137 (1980): 1157.

[4] Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Washington, DC: the American Psychiatric Association, 2000).

[5] Worth Kilcrease, "Is 'Grief Counseling' Helpful or Harmful to the Bereaved?" in Psychology Today (May 9, 2008), no page given. (Drawn from the Psychology Today website, http://www.psychologytoday.com/blog/the-journey-ahead/200805/is-grief-counseling-helpful-or-harmful-the-bereaved)

[6] Wordon, Grief Counseling, 71-74.

[7] If you would like to consider a biblical example of complicated grief, try a close review of King David's grief over the death of his son Absalom (2 Samuel 18-19).

[8] These are the most serious of the signs offered by J. Shep Jeffreys in his helpful book, Helping Grieving People: When Tears Are Not Enough (New York: Brunner-Routledge, 2005), 266-68.

[9] Jeffreys, Helping Grieving People, 280-281. Worden, Grief Counseling, 65-70. Therese Rondo, Grief, Dying and Death (Champaign, IL: Research Press Company), 1984, 43-57, 64-68

[10] Worden, Grief Counseling, 74-77.

[11] In Maine, the pastor is encouraged to seek to persuade the person to get help, physically take him or her to a facility where help may be obtained, obtain a promise from the person that he or she will not kill himself or herself, or if these fail, to report the matter by calling the state hotline. Each of you should know what reporting requirements your state places upon you as a religious professional and as a church.

Gordon H. Cook is the pastor of Merrymeeting Bay Orthodox Presbyterian Church in Brunswick, Maine. He coordinates a Pastoral Care (Chaplain) program for Mid Coast Hospital and its affiliated extended care facility and has an extensive ministry as a hospice chaplain with CHANS Home Health in Brunswick. Ordained Servant Online, May 2011.