We have all experienced the pain caused by grief and loss at some point, but when individuals present maladaptive responses in their healing journey, it can have a tremendous impact on their mental health and physical well-being, making it difficult for them to resume their daily lives.

Those whose grief does not lessen over time (or even worsens) may have feelings of anger, guilt, anxiety, numbness, or denial; problems eating or sleeping; or engage in unhealthy or destructive behavior, including suicidal ideation. These intense feelings may last months or even years, as some individuals attempt to avoid addressing their loss, while others surround themselves with reminders.

Lisa A. Rainwater, MA, PhD, NCC, CT, LCMHCA, specializes in counseling clients experiencing grief, anxiety, existential threats, life-threatening illnesses, end-of-life decisions, and healers’ and helpers’ burnout. She recently shared her insights into complicated grief and working with clients who are experiencing it.

“While each individual responds to loss uniquely—and each loss evokes a unique response—our worldview and belief system buoy our early coping strategies throughout our life’s journey,” she says. “Some may be adaptive, and others maladaptive.” 

“Maladaptive grief can occur when the loss disrupts an individual’s sense of self and upends one’s worldview,” Rainwater continues. “A violent death, such as a mass shooting, can make one question the safety and sanctity of life. The death of a child can make one question the purpose and meaning of life in a harsh, unjust world. The inability to make sense of a loss and difficulties in reconstructing one’s life in that absence can lead to maladaptive coping strategies and/or complicated grief.”

Certain losses may lead to maladaptive grief due to a lack of social support and/or recognition. Disenfranchised grief is experienced when the loss is invalidated or unrecognized by one’s family, society, or culture. The loss or relationship may be stigmatized (e.g., suicide/homicide; same-sex partner) or viewed as insignificant (e.g., miscarriage or loss of a pet). Ambiguous loss is experienced when what has been lost is not readily acknowledged, as in the case of a client mourning the loss of their loved one who is alive but unreachable due to Alzheimer’s Disease.

“In the absence of social validation and support, clients may turn inward to avoid pressures to ‘move on,’ or ‘get another pet,’ or ‘try again,’ Rainwater continues. “Changes in behavior may include social withdrawal, increased alcohol or drug use, and ruminating thoughts such as intense yearning. Symptoms that mimic depression such as anhedonia, hopelessness, sleep disruptions, changes in appetite, and suicidal ideation can also be a sign that a client is experiencing difficulties in accepting the reality of their loss.”

Maladaptive grief can take a hefty toll on a person’s emotional and physical well-being.

"The most vital elements of living can fall to the wayside: nutrition, hydration, sleep, exercise, and social support,” Rainwater says. “A spouse grieving a partner of 40 years may find it difficult to make and eat meals without their loved one to share the experience, causing them to lose weight and become dehydrated. A grieving child may find it difficult to fall asleep, believing he will join his beloved pet who is ‘at sleep now,’ causing lack of concentration and behavioral outbursts in school. An elderly woman grieving her sister and walking partner may abstain from her daily walks and exercise, risking muscle and bone weakness, metabolic changes, and a lowered immune system.”

Complicated grief is not the same as depression or Post-Traumatic Stress Disorder (PTSD), Rainwater says.

“Some expressions of complicated grief can mimic those of depression, but they are different presenting issues. The deceased person is at the heart of complicated grief: A client’s affects, cognitions, and behaviors are tethered to the person they lost and make it difficult for them to reconstruct a life without that person,” she says. “Depression is less about specificity and more about a general state of malaise that encompasses one’s entire existence, accompanied by feelings of hopelessness and worthlessness and psychomotor retardation. Psychotherapy and pharmacotherapy are evidence-based approaches for treating depression, whereas individual and group psychotherapy are proven evidence-based approaches for treating complicated grief.

“PTSD is an affective, cognitive, and behavioral response to an actual or threatened traumatic event,” she continues. “The traumatic event is at the heart of PTSD. Symptoms include reliving the event (e.g., nightmares or flashbacks); avoidance; negative thoughts and feelings such as shame, guilt, anger, memory loss, or difficulty in trusting others; and hyperarousal. A client may present with complicated grief and PTSD, if, for example, they witnessed the death of a loved one.”

To help clients experience and embrace the emotional storms of grief, Rainwater likes to use a metaphor of the American buffalo, she says.

"While domestic cattle try to outrun a storm, buffalo instinctually know they must face the storm head on,” she says. “Buffalo suffer less, conserve energy, and spend far less time in the freezing rain, drizzle, high winds, and snow. In contrast, cattle suffer longer, exert more energy, and spend more time in the chaos of a storm. As counselors, we can help our clients face the storm and reduce suffering.”

Lisa A. Rainwater, MA, PhD, NCC, CT, LCMHCA, is the owner of Rainwater Counseling in Winston-Salem, North Carolina. She earned a master’s in German studies from the University of Oregon; a master’s in counseling from Wake Forest University; and a doctoral degree in German and Scandinavian studies from the University of Wisconsin-Madison. She is a Certified Thanatologist through the Association of Death Education and Counseling and is seeking certification in Grief Therapy as Meaning Reconstruction at the Portland Institute for Loss and Transition.