Journal of Loss and Trauma

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Complicated Grief: How is it Conceptualized by

Professionals?

Anne Dodd, Suzanne Guerin, Susan Delaney & Philip Dodd

To cite this article: Anne Dodd, Suzanne Guerin, Susan Delaney & Philip Dodd (2021)
Complicated Grief: How is it Conceptualized by Professionals?, Journal of Loss and Trauma, 26:1,
35-47, DOI: 10.1080/15325024.2020.1722460

To link to this article: https://doi.org/10.1080/15325024.2020.1722460

Published online: 10 Mar 2020.

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JOURNAL OF LOSS AND TRAUMA
2021, VOL. 26, NO. 1, 35–47
https://doi.org/10.1080/15325024.2020.1722460

Complicated Grief: How is it Conceptualized by

Professionals?
Anne Dodda, Suzanne Guerina , Susan Delaneyb, and Philip Doddc
a
UCD School of Psychology, University College Dublin, Dublin, Ireland; bIrish Hospice Foundation,
Dublin, Ireland; cSt Michael’s House Intellectual Disability Service, Dublin, Ireland

ABSTRACT ARTICLE HISTORY

Despite the proliferation of grief research, there is no consen- Received 25 September 2019
sus regarding the naming of grief that does not follow a typ- Accepted 23 January 2020
ical trajectory. How a concept such as grief that has become
KEYWORDS
complicated, is named and understood will likely influence
Complicated grief;
professionals’ engagement with it. Professionals (n ¼ 185; definitions; professional
71.8% female; mean age 51.9 years; SD ¼ 8.9) defined compli- conceptualization
cated grief in a free-text box, within a survey. Statistically sig-
nificant differences were found regarding extended duration,
being stuck, and the circumstances surrounding the death. The
differences in professionals’ views of complicated grief and its
multidisciplinary nature underscore the need for consensus
regarding its nomenclature and definition.

Introduction
The International Classification of Diseases (ICD-11, World Health
Organization, 2018) includes for the first time a diagnosis of prolonged
grief disorder (PGD). Grief that does not follow the usual trajectory has
been variously labeled by researchers: absent (Deutsch & Jackson, 1937);
delayed, morbid, distorted (Lindemann, 1944); atypical (Hammett, Cavenar,
Maltbie, & Sullivan, 1979); dysfunctional (Rancour, 1998); abnormal
(Pasnau, Fawzy, & Fawzy, 1987); chronic (Lasker & Toedter, 1991); patho-
logical (Horowitz, Bonanno, & Holen, 1993; Middleton, Raphael, Martinek,
& Misso, 1993); traumatic (Jacobs, Mazure, & Prigerson, 2000); complicated
(Shear, Frank, Houck, & Reynolds, 2005); maladaptive (de Groot et al.,
2007); prolonged grief disorder (Prigerson et al., 2009); complex (Boelen,
2016); unresolved (Bylund-Grenklo, F€ urst, Nyberg, Steineck, & Kreicbergs,
2016). It was included in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5, American Psychiatric Association, 2013) as a condition
for which further study is recommended and named persistent complex
bereavement disorder (PCBD).

CONTACT Suzanne Guerin suzanne.guerin@ucd.ie UCD School of Psychology, University College Dublin,
Newman Building, Belfield, University College Dublin, Dublin 4, Ireland.
ß 2020 Taylor & Francis Group, LLC
36 A. DODD ET AL.

Therese Rando has commented that “without trying to be humorous,

complicated grief is quite complicated” (Rando, 2013, p. 40). A shared
operational definition of a concept such as this enhances professional dis-
course and affords clear communication between researchers and practi-
tioners. It may also allow both mental health and other support
professionals to communicate better with their clients and patients regard-
ing their needs. How a concept such as grief that has become complicated
is named and understood will likely influence professionals’ engagement
with it (Arney & Scott, 2013). Moreover, a shared understanding of
language around the concept enhances effective teamwork and inter-agency
work making good client outcomes more likely. Working with complicated
grief, and grief, in general, is the domain of a wide variety of professions.
Mental health professionals undergo different training depending on
their precise discipline and may view a concept such as complicated grief
through quite different lenses. While there is a small body of research on
professionals’ views of complicated grief (Dodd, Guerin, Delaney, & Dodd,
2017), there is little explicit consideration of how practitioners define this
important context. One implication of variation in understanding is the
inconsistent onward referral of individuals requiring support with more
complicated grief reactions. The aim of this short paper was to present an
initial exploration, as a prompt to further research, of how a relatively large
sample of psychiatrists, psychologists, and counselors/psychotherapists
viewed this concept. While the focus is not on participants’ formal defini-
tions of complicated grief, their responses will provide an important insight
into patterns related to this important concept.

Methods
Study design
Mindful of the extensive nomenclature associated with what constitutes
complicated grief and recognizing that an understanding of this concept
may vary across professions, a sample of mental health professionals, par-
ticipating in a wider survey, were invited to share their own understanding
of complicated grief in a free–text box. The invitation was prefaced with
the following text:
Complicated grief is an umbrella term used to encompass various presentations of
grief suggesting excessive distress, beyond what would be considered usual for most
people. Other terms associated with complicated grief include Traumatic Grief,
Prolonged Grief Disorder, Persistent Complex Bereavement Disorder among others.
It may be described differently by different groups of mental health professionals.

The intention of providing a rudimentary description such as this was to

stimulate reflection by the participants. However, no information was
 JOURNAL OF LOSS AND TRAUMA 37

provided on the factors that might trigger the excessive distress referred to,
in order to minimize any potential bias this description might generate.

Study population
Participants were recruited through the publicly available databases of their
professional bodies. Of the 185 professionals (71.8% female; mean age
51.9 years (SD ¼ 8.9)) who participated in the overall survey, a total of 168,
comprising 35 psychiatrists, 93 counselors/psychotherapists and 40 psychol-
ogists, chose to provide a definition. A further two psychiatrists simply
stated, “as above,” indicating agreement with the umbrella definition given
in the questionnaire.

Data analysis
The professionals’ understanding of the concept was analyzed using a
three-pronged approach. Firstly, in order to focus the process, a Wordle of
the data was created using http://www.wordle.net/. A Wordle is a represen-
tation of text which gives greater prominence to the words that appear
more frequently in the source text. It is a useful means of quickly gaining a
visually rich overview of patterns in the data (McNaught & Lam, 2010).
Using the Wordle system, common English words were removed, all words
were made lower case, and words were left as spelled in the text.
Having obtained an overall visual sense of the conceptualizations pro-
vided, the second prong in the analysis of these perspectives was to carry
out a total word frequency, the assumption being that the words which
appear most frequently, reflect the most important concerns of the text
(Stemler, 2001). Additionally, the table of frequencies is useful in identify-
ing those words which lack numerical support, so that any unexpected
ideas might be picked up. These words were initially produced from great-
est to lowest frequency but were then alphabetized, so that words repre-
senting similar ideas such as suicide, suicidality, and suicidal, for example,
would be side-by-side, and therefore easier to aggregate.
However, in both the Wordle and the word frequencies table, the words
are de-contextualized and as Feinberg (2010), the creator of the Wordle
points out, word counts alone do not allow for any meaningful comparison
of concepts. The first two steps in the analysis of the conceptualizations
provided by the professionals, the Wordle and the word frequencies were
conducive to the researcher’s total immersion in the data and facilitated the
execution of the third prong, the thematic analysis (Braun & Clarke, 2006)
at the semantic level. Line-by-line coding was carried out across the entire
data set and then data relevant to each code were collated. Similar codes
38 A. DODD ET AL.

Figure 1. Wordle - graphical representation of data.

were then collated, and candidate themes were generated. As a consistency

check, a second reviewer (SG) independently coded 20% of the transcripts
and also generated candidate themes from these. These two authors shared
and discussed the codes and candidate themes arrived at independently
and reconciled any discrepancies through discussion. Candidate themes
were reviewed across the entire data set to check for inconsistencies,
merged by the researcher and then final themes were defined and named.

Results
The resulting visual image is presented in Figure 1. Unsurprisingly, grief,
complicated, loss, and person are prominent words in professionals’ con-
ceptualizations of complicated grief, but these add no new perspective on
the nature of complicated grief. Some relevant words that appear to be
prominent are normal, process, symptoms, stuck, feelings, distress, relation-
ship, circumstances, reaction, significant, words relating to functioning, and
words relating to duration such as prolonged, persistent, time, and period.
Since words with a similar root were seen as individual words for the
Wordle, certain concepts may have appeared to have less prominence than
was actually the case. An example of this is function and functioning,
which are displayed separately on the Wordle, while essentially referring to
the same aspect of complicated grief.
The results of the total word frequency for phrases in the participants’
responses are shown in Table 1.
 JOURNAL OF LOSS AND TRAUMA 39

TABLE 1 Alphabetical word frequencies from definitions of complicated grief.

6 ability 14 functioning 4 resolution
5 abnormal 2 homicide 1 rumination
2 ambivalent 3 impaired 8 severe
10 anxiety 4 impairment 5 severity
4 attachment 10 inability 3 stage
1 atypical 6 intense 10 stages
18 beyond 7 intensity 16 stuck
2 child 4 lasting 3 “stuck”
5 chronic 2 length 2 stuckness
10 circumstances 2 lengthy 1 “stuckness”
7 complex 8 long 5 sudden
6 cope 8 longer 2 suddenly
7 coping 1 manslaughter 2 suicidal
3 crime 14 months 1 suicidality
1 criminal 6 mood 7 suicide
8 delayed 1 murder 11 terms
1 depressed 1 murdered 1 timely
6 depression 1 murders 5 trauma
5 depressive 4 natural 1 traumas
12 difficult 30 normal 11 traumatic
7 disorder 2 “normal” 1 traumatically
18 distress 3 overwhelming 5 trigger
4 distressing 3 pathological 2 triggered
6 duration 16 period 2 triggers
1 elongates 3 persist 17 unable
8 emotions 15 persistent 2 unending
3 entrenched 1 persisting 1 unexpected
4 excessive 3 persists 3 unfinished
9 expected 2 pervasive 1 unprepared
16 feelings 1 phase 1 unrelenting
5 forward 1 phases 10 unresolved
2 frozen 1 pining 1 violences
9 function 48 prolonged 5 violent
1 functional 13 relationship 6 years
3 functionally 4 relationships 1 yearning

It must be noted that the frequencies refer to the words and not to
the number of professionals who used these words in their conceptuali-
zations of the concept. This caveat notwithstanding, in total, there were
121 mentions of words that pertained to duration (prolonged, persist,
elongates, timely, unrelenting, etc.), which gives an indication of the
importance of this particular concept in the perspectives proffered.
Similarly, there were 39 examples of words which referred directly to
the death occurring in some type of traumatic circumstances. Words
lacking numerical support also add to the pattern of the data. For
example, it is worth noting that pining, yearning, and rumination each
received only a single mention.
The themes considered markers of complicated grief by the professionals
arising from this third prong are shown in Table 2. The sample codes give
some indication of the manner in which the information was grouped, and
typical quotes are given for illustrative purposes.
As can be seen from Table 2, the marker of complicated grief most fre-
quently mentioned by professionals was the extended duration of the
40 A. DODD ET AL.

TABLE 2 Themes arising from professionals’ definitions of complicated grief with illustra-
tive quotes.
No of
professionals
[n ¼ 185 (%)];
(Missing
Theme Sample codes Sample quote values n ¼ 17)
Extended duration Chronic; unusually Complicated grief is a non-self-limiting 91 (54.2)
long; prolonged process.
extended; Grief that is prolonged. Grief that has no
persistent ending and is unrelenting.
Level of distress Severity; intensity Grief that is incredibly overwhelming and 44 (26.2)
crippling even after time has elapsed.
Grief where the distress is severe/extreme.
Impairment of Unable to cop; Grief that makes it difficult for the person 44 (26.2)
functioning to carry on with day-to-day life.
Inability to cope with daily life and to
engage in a meaningful way of life
without the person who has died.
Being stuck Stuck; unable to Someone becomes so lost in their grief 33 (19.6)
move on that their whole life is paralyzed.
It typically presents as an inability to move
on or move forward with their lives.
Traumatic or other Suicide; death of a Complicated grief arises out of a 32 (19.1)
circumstances child; multiple traumatic death.
losses at once It usually happens when a person
experiences two or more losses in
close temporal proximity.
Concept distinct from Beyond normal; It requires treatment whereas normal 31 (18.5)
normal grief beyond what grief does not.
would Grief in excess of what is considered the
be expected normal grieving process.
Co-morbidity (such as Depression; They have prolonged feelings of low self- 25 (14.9)
depression anxiety; worth, depression, disturbed sleep.
and anxiety) anhedonia Grief complicated by significant co-
morbid mental illness.
Theoretical reference Stages; Failure to progress through the expected 18 (10.7)
phases; stages of grief following a bereavement.
attachment Complicated grief carries at least some
degree of attachment wounding.
Relationship with Difficult; It can occur if the person has had a 14 (8.3)
the deceased ambivalent; difficult relationship with the person
unresolved who has died.

grieving period. An actual length of time, after which complicated grief was
indicated, was mentioned by 17 people (54.2%), with the time post-loss
ranging from 3 months to 2 years. The level of distress and impairment of
functioning being experienced by the grieving person were referred to with
equal frequency in the conceptualizations shared, being mentioned by
26.2% of the professionals. An inability to move on with one’s life or of
being stuck in one’s grief was a theme mentioned by almost 20% of the
respondents. Traumatic or other circumstances surrounding the death were
deemed to contribute to the development of complicated grief by 19.1% of
professionals. In some cases, the nature of the circumstances was not
detailed but violent death, death by suicide, sudden death and the death of
a child were given as examples of circumstances likely to contribute to the
development of complicated grief.
 JOURNAL OF LOSS AND TRAUMA 41

TABLE 3 Comparison of themes by profession.

Counselors/
Psychiatrists psychotherapists Psychologists
Theme Total (n ¼ 185) (n ¼ 39) (n ¼ 103) (n ¼ 43) p-Value
Missing values n ¼ 17 n¼4 n ¼ 10 n¼3
Extended duration 91(54.2%) 22(62.9%) 41(44.1%) 28(70.0%) 0.012
Level of distress 44(26.2%) 8(22.9%) 20(21.5%) 16(40.0%) 0.074
Impairment of functioning 44(26.2%) 12(34.3%) 21(22.6%) 11(27.5%) 0.397
Being stuck 33(19.6%) 2(5.7%) 24(25.8%) 7(17.5%) 0.036
Traumatic or other circumstances 32(19.1%) 0(0.0%) 27(29.0%) 5(12.5%) 0.001
Concept distinct from normal grief 31(18.5%) 9(25.7%) 12(12.9%) 10(25.0%) 0.118
Co-morbidity (such as depression 25(14.9%) 9(25.7%) 10(10.8%) 6(15.0%) 0.106
and anxiety)
Theoretical reference 18(10.7%) 4(11.4%) 11(11.8%) 3(7.5%) 0.752
Relationship with the deceased 14(8.3%) 3(8.6%) 7(7.5%) 4(10.0%) 0.893

In 18.5% of the responses offered, respondents used their understanding

of normal grief as a comparator and referred to complicated grief as a con-
cept distinct from normal grief. Although there was no view shared as to
what constitutes a “normal” grieving process, the idea was that complicated
grief is recognizable because it is “beyond the normal range of grief
response” or is “beyond what would be expected in the circumstances.”
Complicated grief was seen as being accompanied by, or leading to, co-
morbidity (such as depression and anxiety) in 14.9% of the responses. It
was asserted that the loss, in addition to giving rise to natural grief, might
also trigger depression, anxiety or other latent tendencies. The professio-
nals’ understanding of complicated grief was guided in 10.7% of cases by
their theoretical reference. Stage, phase or task models were mentioned.
Attachment insecurities were also cited as underpinning a complicated grief
response. The final theme from the definitions was that grief could become
complicated due to the nature of the relationship with the deceased and
this was seen as a factor by 8.3% of the professionals. A relationship which
was difficult, unresolved or ambivalent was seen as being a contributory
factor to complication in the grieving process.
Table 3 shows the breakdown of the themes by profession and illustrates
between-profession differences. From this table, it can be seen that the psy-
chiatrists and psychologists placed greater importance on the extended dur-
ation of grief as a marker of complication than did counselors/
psychotherapists and the between-group differences were statistically sig-
nificant (p ¼ 0.012). The psychologists were most emphatic on this point,
with 70% of them citing this as an indicator of complicated grief. The per-
haps related idea of being stuck in one’s grief was part of the conceptuali-
zations for over a quarter of counselors/psychotherapists but was
mentioned only by 17.5% of the psychologists and by two of the 35 psy-
chiatrists (5.7%) and again the difference was statistically significant
42 A. DODD ET AL.

(p ¼ 0.036). However, if these two themes are aspects of one conceptualiza-

tion it may explain the disciplinary differences noted, with more consistent
reports evident when the themes are collapsed.
Regarding the circumstances surrounding the death (death by suicide,
death of a child, homicide, for example) there was a significant difference
between the responses of the three groups (p ¼ 0.001). None of the psychia-
trists mentioned this as a factor, only five (12.5%) of the 40 psychologists
did, while 29.0% of counselors/psychotherapists considered it as a marker.
Regarding the remaining six markers, level of distress, impairment of func-
tioning, concept distinct from normal grief, co-morbidity, theoretical refer-
ence and relationship with the deceased, there was no statistically
significant difference between the three groups.

Discussion
The reflections on the nature of complicated grief proffered by the profes-
sionals give some idea of how the term is conceptualized by the three pro-
fessional groupings. Some referred to complicated grief as a concept
distinct from normal grief, but, while there were some commonalities,
belief as to what constitutes a grief process requiring intervention varied
with the profession. The literature recognizes that professionals’ personal
feelings about death and dying may impact their ability to engage with
patients or clients experiencing difficulty following bereavement (Pasnau
et al., 1987).
One of the most telling features of the perspectives shared by participants
was the reliance on the extended duration of grief as a marker of complica-
tion, especially among psychiatrists and psychologists. Though as noted
above, if the concept of being stuck is also taken to reflect duration rather
than perhaps an inability to move on, then this is an even more prevalent
conceptualization across groups. Another important dimension was the
emphasis placed by counselors/psychotherapists on the circumstances of
the death. It is undoubtedly the case that traumatic deaths pose particular
difficulties for the griever (Raphael, Martinek, & Wooding, 2004) and lead
to a higher incidence of complicated grief. It must be noted, however, that
complications can also arise following seemingly timely death (Kersting,
Br€ahler, Glaesmer, & Wagner, 2011; Wiles, Jarrett, Payne, & Field, 2002).
As McDaniel and Clark (2009) point out the death of the last surviving
parent can have a profound effect on survivors, whom they term “adult
orphans” (p. 44), leaving them at risk of developing complicated grief. If a
professional regards complicated grief as that which arises primarily as a
result of traumatic circumstances, this may affect the support received by
these adult orphans. It must be noted, however, that there are also
 JOURNAL OF LOSS AND TRAUMA 43

researchers who oppose the classification of complicated grief as a disorder,

stating that the diagnostic criteria proposed are not yet sufficiently strin-
gent and that making such a diagnosis runs the unacceptable risk of many
false-positives being identified (Wakefield, 2013).
The professionals’ view of the role of the quality of the relationship in
the development of complicated grief may have implications for clinical
practice. A small number (8.3%) of the professionals were of the view that
having had a difficult or ambivalent relationship with the deceased was a
contributory factor to grieving complications. However, Piper et al. (2001)
found that an ambivalent relationship was inversely related to the severity
of grief symptoms. Conversely, in another study, a higher degree of depth
or closeness in the relationship with the deceased has been found to be
associated with experiencing more complicated grief (Mash, Fullerton,
Shear, & Ursano, 2014). Moreover, that study also found no significant
association between having had a conflictual relationship with the deceased
and complicated grief.
In all three of the existing diagnostic criteria sets—American
Psychiatric Association (2013), Prigerson et al. (2009), and Shear et al.
(2011)—yearning, pining and longing for the deceased are key markers of
complicated grief. This is an important distinguishing feature between com-
plicated grief and major depressive disorder (Robinaugh, Marques, Bui, &
Simon, 2012) and an essential element of the ICD-11 (World Health
Organization, 2018) criteria. However, it was mentioned only three times in
the responses proffered by the professionals. In the absence of accurately rec-
ognizing complicated grief, it is not unlikely that it might be inappropriately
treated as depression (Shear, Muldberg, & Periyakoil, 2017; Shear et al.,
2011). If complicated grief is regarded as simply a “re-labelling” (Hall, 2014)
of other conditions, patients and clients may receive an inappropriate inter-
vention. It must, however, be recognized that the participants in the study
represent a self-selected sample, with their existing views of complicated
grief potentially impacting on participation. The variation in the understand-
ing of complicated grief reported by the different professional groupings
may have implications for how they respond to their patients and clients.
The three areas of statistically significant variation between the professional
groupings were extended duration, being stuck in one’s grief and the death
having arisen from traumatic circumstances. There may also be implications
here for the tailoring of complicated grief training for these groups.

Limitations and conclusion

This paper gives a snapshot of the views of a relatively large body of profes-
sionals on their understanding of complicated grief. In the context of the
44 A. DODD ET AL.

limited research examining professionals’ engagement with complicated grief,

this adds additional insight to the existing literature. However, it is important
to consider the limitations of this study as an exploration of professionals’
views. It must be stressed that the findings are based on a single question
exploring the professionals’ descriptions of this concept. We note that partici-
pants were provided with one framing of complicated grief as a concept.
However, we feel the benefits of providing a prompt to stimulate reflection
outweigh the potential influence this may have had on professionals’
responses . If the study had focused on trainees or students, they may have
been more influenced, however, we would argue that the focus on experi-
enced practitioners makes any negative influence less likely. It must be noted
also that in the word frequency table, the frequencies refer to the words them-
selves and not to the number of professionals who used these words, so it is
possible that this may skew any interpretation that may be made.
It is natural that concepts may come to be differently understood by dif-
ferent professional groupings (Arney & Scott, 2013) and it appears that this
is the case with complicated grief. This may arise as a result of varying lev-
els of exposure to the concept in training, or in the workplace setting, or
the professional’s worldview of grief may also impact. In the current study,
grief having an extended duration was regarded as being a more important
marker of complication for psychiatrists and psychologists than for counse-
lors/psychotherapists. This latter group placed greater stress on the role of
traumatic or other circumstances in the development of complicated grief
than did psychiatrists and psychologists, which may give rise to certain
grief presentations nor receiving support. Being stuck in one’s grief fea-
tured in the responses of psychologists and counselors/psychotherapists but
not of psychiatrists.
The multidisciplinary nature of complicated grief and of the professionals
who engage with it underscores the need for having consensus regarding
its nomenclature and definition. The inclusion of prolonged grief disorder
in the recently published ICD-11 is to be welcomed as it brings much-
needed clarity to the research landscape. It is to be hoped that the DSM in
its next incarnation will follow suit.

Ethical approval
The research was approved by the UCD Human Research Ethics Committee:
Humanities Committee.

Author contributions
All authors made substantial contributions to the development and design of the research.
The first author led on the analysis and interpretation, supported by the other authors.
 JOURNAL OF LOSS AND TRAUMA 45

All authors contributed to the drafting of this article and have approved it for publication.
All authors are accountable for the work.

Disclosure statement
No financial interest or benefit has arisen from the application of the research.

Funding
This work was supported by the Irish Hospice Foundation, under the Therese Brady
Scholarship.

Notes on contributors
Anne Dodd is a psychotherapist in private practice and completed her PhD, as the Irish
Hospice Foundation Therese Brady Scholar, at the UCD School of Psychology under the
supervision of Dr Suzanne Guerin.
Suzanne Guerin is an Associate Professor in Research Design and Analysis with the UCD
School of Psychology, with an interest in health service research.
Susan Delaney is a clinical psychologist and was based at the Irish Hospice Foundation for
the duration of the research, where she was the Director of the Complicated
Grief Program.
Philip Dodd is the Head of the Department of Psychiatry with St Michael’s House
Disability Services and serves as Clinical Advisor to the Irish National Office for
Suicide Prevention.

ORCID
Suzanne Guerin http://orcid.org/0000-0002-6744-7590

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disor-
ders (DSM-5) (5th Ed.). Washington, DC: American Psychiatric Publishing.
Arney, F., & Scott, D. (Eds.). (2013). Working with vulnerable families: A partnership
approach. Cambridge, UK: Cambridge University Press.
Boelen, P. A. (2016). Improving the understanding and treatment of complex grief: An
important issue for psychotraumatology. European Journal of Psychotraumatology, 7(1),
32609. doi:10.3402/ejpt.v7.32609
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research
in Psychology, 3(2), 77–101. doi:10.1191/1478088706qp063oa
Bylund-Grenklo, T., F€ urst, C. J., Nyberg, T., Steineck, G., & Kreicbergs, U. (2016).
Unresolved grief and its consequences. A nationwide follow-up of teenage loss of a par-
ent to cancer 6-9 years earlier. Supportive Care in Cancer: Official Journal of the
Multinational Association of Supportive Care in Cancer, 24(7), 3095–3103. doi:10.1007/
s00520-016-3118-1
46 A. DODD ET AL.

Deutsch, H., & Jackson, E. (1937). Absence of grief. The Psychoanalytic Quarterly, 6(1),
12–22. doi:10.1080/21674086.1937.11925307
Dodd, A., Guerin, S., Delaney, S., & Dodd, P. (2017). Complicated grief: Knowledge, atti-
tudes, skills and training of mental health professionals: A systematic review. Patient
Education and Counseling, 100(8), 1447–1458. doi:10.1016/j.pec.2017.03.010
Feinberg, J. (2010). Wordle. In J. Steele & N. Iliinsky (Eds.), Beautiful visualization:
Looking at data through the eyes of experts. Sebastopol, CA: O’Reilly Media, Inc
de Groot, M., de Keijser, J., Neeleman, J., Kerkhof, A., Nolen, W., & Burger, H. (2007).
Cognitive behaviour therapy to prevent complicated grief among relatives and spouses
bereaved by suicide: Cluster randomised controlled trial. British Medical Journal,
334(7601), 994–999.
Hall, C. (2014). Bereavement theory: Recent developments in our understanding of grief
and bereavement. Bereavement Care, 33(1), 7–12. doi:10.1080/02682621.2014.902610
Hammett, E. B., Cavenar, J. O., Jr, Maltbie, A. A., & Sullivan, J. L. (1979). Atypical grief:
Anniversary reactions. Military Medicine, 144(5), 320–321. doi:10.1093/milmed/144.5.320
Horowitz, M., Bonanno, G., & Holen, A. (1993). Pathological grief: Diagnosis and explan-
ation. Psychosomatic Medicine, 55(3), 260–273.
Jacobs, S., Mazure, C., & Prigerson, H. (2000). Diagnostic criteria for traumatic grief. Death
Studies, 24(3), 185–199. doi:10.1080/074811800200531
Kersting, A., Br€ahler, E., Glaesmer, H., & Wagner, B. (2011). Prevalence of complicated
grief in a representative population-based sample. Journal of Affective Disorders,
131(1–3), 339–343. doi:10.1016/j.jad.2010.11.032
Lasker, J. N., & Toedter, L. J. (1991). Acute versus chronic grief: The case of pregnancy
loss. American Journal of Orthopsychiatry, 61(4), 510–522. doi:10.1037/h0079288
Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal
of Psychiatry, 101(2), 141–148. doi:10.1176/ajp.101.2.141
Mash, H. B. H., Fullerton, C. S., Shear, M. K., & Ursano, R. J. (2014). Complicated grief
and depression in young adults: Personality and relationship quality. The Journal of
Nervous and Mental Disease, 202(7), 539–543. doi:10.1097/NMD.0000000000000155
McDaniel, J. G., & Clark, P. G. (2009). The new adult orphan: Issues and considerations
for health care professionals. Journal of Gerontological Nursing, 35(12), 44–49. doi:10.
3928/00989134-20090930-02
McNaught, C., & Lam, P. (2010). Using Wordle as a supplementary research tool. The
Qualitative Report, 15(3), 630–643. Retrieved from http://nsuworks.nova.edu/tqr/vol15/
iss3/8/
Middleton, W., Raphael, B., Martinek, N., & Misso, V. (1993). Pathological grief reactions.
In M. Stroebe, W. Stroebe, & R. O. Hansson (Eds.), Handbook of bereavement: Theory,
research and intervention (pp. 44–61). New York, NY: Cambridge University Press.
Pasnau, R. O., Fawzy, F. I., & Fawzy, N. (1987). Role of the physician in bereavement. The
Psychiatric Clinics of North America, 10(1), 109–120.
Piper, W. E., Ogrodniczuk, J. S., Joyce, A. S., Mccallum, M., Weideman, R., & Azim, H. F.
(2001). Ambivalence and other relationship predictors of grief in psychiatric outpatients.
The Journal of Nervous and Mental Disease, 189(11), 781–787. doi:10.1097/00005053-
200111000-00008
Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., …
Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria
proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121. doi:10.1371/journal.
pmed.1000121
 JOURNAL OF LOSS AND TRAUMA 47

Rancour, P. (1998). Recognizing and treating dysfunctional grief. In Oncology Nursing

Forum, 25(8), 1310–1311.
Rando, T. A. (2013). On achieving clarity regarding complicated grief: Lessons from clinical
practice. In M. S. Stroebe, H. Schut, & J. Van den Bout (Eds.), Complicated grief:
Scientific foundations for health care professionals (pp. 40–54). Hove, UK: Routledge.
Raphael, B., Martinek, N., & Wooding, S. (2004). Assessing traumatic bereavement. In J. P.
Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp.492–510).
New York, NY: Guilford Press.
Robinaugh, D. J., Marques, L., Bui, E., & Simon, N. M. (2012). Recognizing and treating
complicated grief. Current Psychiatry, 11(8), 30–35.
Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated
grief: A randomized controlled trial. JAMA, 293(21), 2601–2608. doi:10.1001/jama.293.
21.2601
Shear, M. K., Muldberg, S., & Periyakoil, V. (2017). Supporting patients who are bereaved.
British Medical Journal, 358.
Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., … Keshaviah, A.
(2011). Complicated grief and related bereavement issues for DSM-5. Depression and
Anxiety, 28(2), 103–117. doi:10.1002/da.20780
Stemler, S. (2001). An overview of content analysis. Practical Assessment, Research &
Evaluation, 7(17), 137–146.
Wakefield, J. C. (2013). The DSM-5 debate over the bereavement exclusion: Psychiatric
diagnosis and the future of empirically supported treatment. Clinical Psychology Review,
33(7), 825–845. doi:10.1016/j.cpr.2013.03.007
Wiles, R., Jarrett, N., Payne, S., & Field, D. (2002). Referrals for bereavement counselling in
primary care: A qualitative study. Patient Education & Counseling, 48(1), 79–85. doi:10.
1016/S0738-3991(02)00068-X
World Health Organization. (2018). ICD-11, the 11th revision of the International
Classification of Diseases. Geneva, Switzerland: World Health Organization.