Complex grief can be treated

A death is said to have a non-natural violent cause when it involves homicide, suicide, or an act of war, or when it occurs in complex circumstances such as when someone goes missing or is lost together with others. The Netherlands experiences about 1750 suicides, 130 murders, and 550 missing person cases each year. As a result, each year between 10,000 and 15,000 next of kin experience the consequences of non-natural deaths.

Not every complex loss leads to complex grief. However, it does increase the risk for complex grief, especially if the next of kin is not provided with psychological care. After a suicide, about 40% of surviving relatives experience complex grief. After a murder, the number is as high as 80%. In both groups, the currently available evidence-based is used in only one-third of the cases. Thus, there is a “treatment gap” of 67%. This number is very large compared to the treatment gap for medical problems such as diabetes (8%), but also compared to the treatment gap for other psychological problems such as depression (56%).


The violence of the loss is more likely to make grief more complex than its unexpectedness. The traumatic memories of the death are difficult to integrate into the autobiographical memory. Besides, the cause of death lies far beyond one’s imagination. Surviving relatives are not mentally prepared for these types of events, which therefore cannot be placed in any existing frame of reference. As a result, the relatives experience unfamiliar thoughts, unknown emotions, and changed behavior.

The bereaved often attempt to avoid the memories related to the loss, so as not to become emotionally overburdened. This avoidance can take different shapes, such as feeling guilty after suicide, feeling angry and vengeful after murder, and ruminating after someone has gone missing. Many relatives experience an existential crisis when going through these emotions, which causes a lot of stress.

After murder, surviving relatives tend to develop assumptions about the world being unsafe. In a missing person case, relatives often view the world as a mysterious place, and after suicide their ideas are commonly framed in terms of helplessness and guilt. Later, after experiencing disappointment in the authorities or in the people surrounding them, many relatives develop assumptions about the world being unjust, and about having been marginalized as a victim by society. Mariette van Denderen is the PhD student who found these results in a study in Groningen (


Psychological treatments are effective in reducing the mental health complaints of the bereaved. Treatment programs appear to be most effective when targeted specifically towards the appropriate type of complex grief, since different emotions and thoughts are complicating grief in different situations. For instance, after suicide the surviving relatives often experience feelings of guilt or rejection. They tend to try to conceal the cause of death from others. They often look for clues that can explain the loss of their loved one, for example in the person’s farewell letter. They relive their last moments with the deceased over and over again and search for clues. The bereaved find it extremely difficult to understand and accept why their loved one decided to leave them. The limited research to date has shown that a 20-hour group program can significantly reduce the symptoms of grief after six months (De Groot et al, 2008).

Relatives whose loved one is missing often deal with a multitude of emotions, such as sorrow, guilt, and anger. But also they still have hope that the missing relative will return. These hopes can impede coping with the loss. Because of their insecurity about the faith of their lost loved one, parents of missing children usually experience more severe and prolonged stress compared to parents whose child has been murdered.

The relatives of missing persons often become increasingly disappointed and lose their trust in the judicial system, the police, and the media. Professional psychological care for this group is still in an early stage of development. Existing grief interventions do not suffice, due to the ambiguous character of the loss. Currently, experiments using Mindfulness-Based Cognitive Therapy are being conducted in the United Kingdom. Recently, PhD student Lonneke Lenferink was involved in starting a large-scale project in Groningen (

In sum, there is a lot of ground to be covered in the development and study of therapies for the relatives of people who have committed suicide, been murdered, or gone missing. However, effective treatments are increasingly available and bereaved persons can profit from these.


de Groot, M.H., de Keijser, J., Neeleman, J., Kerkhof, A.J.F.M., Nolen, W.A. & Burger, H. (2007) Cognitive-behaviour therapy to prevent complicated grief among suicide bereaved relatives and spouses. A cluster randomized controlled trial. British Medical Journal, 334, 994-996.

More information?

NOTE: Image by Rana Ossama, licenced under CC BY 2.0

Jos is a scientist-practitioner who prefers to combine his clinical work as a clinical psychologist and psychotherapist with scientific research. His endowed chair is focused on developing and evaluating of theoretical founded treatment after a complex loss, i.e. a loss due to suicide, homicide, a missing person, or disasters such as the MH17 airplane crash. Jos combines his research with providing postgraduate education to psychotherapists and clinical psychologists in training. He is the director of the Post Master of Psychology Institute (PPO Opleidingen) and he provides periodic and advanced training on different topics. Finally, Jos is a father of three grown-up children and he likes cycling and playing soccer.

Key references

Van Denderen, M., de Keijser, J., Kleen, M., & Boelen, P.A. (2013). Psychopathology Among Homicidally Bereaved Individuals. A systematic Review. Trauma, Violence & Abuse, doi: 10.1177/1524838013515757

Van Denderen, M., de Keijser, J., Huisman, M., & Boelen, P.A. (2014). Prevalence and Characteristics of self-rated Post-Traumatic Stress Disorder and Complicated grief in Homicidally-bereaved Individuals. Journal of Interpersonal Violence, doi: 10.1177/0886260514555368

Van Denderen, M., de Keijser, J., Gerlsma, C., Huisman, M., & Boelen, P.A. (2014). Revenge and Psychological Adjustment after Homicidal loss. Aggressive Behavior, 40, 504–511.

Boelen, P. A., de Keijser, J., & Smid, G. (2014). Cognitive–Behavioral Variables Mediate the Impact of Violent Loss on Post-Loss Psychopathology. Psychological Trauma: Theory, Research, Practice, and Policy, doi: 10.1037/tra0000018

For more information please visit Jos’ personal website.

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