When loss needs professional help: the signs and where to turn

“It’s not that bad. Other people have been through much worse. I just need to pull myself together.”

This was said by a man who, eight months earlier, had lost the job he had held for twenty years. Since then he had hardly slept, he had stopped going to his bowls club, he no longer met his friends, and his wife had noticed that he drank more in the evenings than before. He did not come to therapy for his own sake. He came because his daughter asked him to. And because he was convinced that “this isn’t the kind of thing that needs a professional”.

Most people do not need a therapist after a loss. I have to say this at the outset, because it is true and because it matters. Grief is not an illness but a natural response to having loved something. But there are moments when a loss gets stuck, when it opens up something old, or when it begins to threaten life itself. This article is about how to recognise those moments — and where to turn in Slovenia once you have.

Any loss, not only death

When we talk about grief, most people think of the death of someone close. But people also grieve for a job, their health, a home, a homeland, a friendship, a plan, or an image of their parents that has crumbled. I wrote about this in The grief nobody acknowledges. Losses like these are often even harder to recognise as a reason to seek help, because the people around you do not acknowledge them. “But you found another job.” “She was only a friend.” “But you recovered.”

So the signs I describe below apply to every kind of loss. Someone who has lost a job can slide into depression just as much as someone who has lost their mother. A woman who has had a miscarriage can develop grief that is just as persistent as a widow’s. What matters is not how big the loss looks from the outside, but what is happening inside the person.

How many people get stuck

In 2017, the Danish psychologist Marie Lundorff and her colleagues pooled data from a number of studies on grief after the death of someone close. They found that roughly one person in ten — 9.8 per cent of adults bereaved through natural causes — develops prolonged grief that does not ease on its own. After sudden and violent deaths the proportion is higher.

This figure tells us two things. First, nine out of ten people come to terms with a loss over time without professional help. Second, that one person is not a rarity. In any larger circle of grieving people there is someone whose grief does not shift. And often it is precisely this person who insists most firmly that “everything is fine”.

For losses other than death we do not have such precise data. But research on job loss, divorce and serious illness shows a similar pattern: most people adapt, while a minority remain stuck in distress that lasts longer and runs deeper than one would expect.

The first sign: grief that does not move

Ordinary grief comes in waves. Hard days alternate with days that are a little easier. Over time the pain does not necessarily diminish, but a person learns to live around it. With complicated or prolonged grief this does not happen. The longing for what was lost stays just as strong for months and years, the person cannot accept that it has happened, and life without it feels meaningless.

This form of grief has recently become an officially recognised diagnosis too. I described it in detail in When grief doesn’t pass: what prolonged grief disorder is, so I will not repeat it here. I will add only this: although the diagnosis is defined for the death of someone close, a similar pattern appears with other losses. A person who, ten years after a divorce, still goes over every day how the marriage could have been saved, is stuck in the same way.

The second sign: when sadness becomes depression

Grief and depression are similar, but they are not the same thing. In grief the pain is directed at the loss: you miss someone or something. Your sense of self stays largely intact. In depression the pain spreads to everything — to the future, to your own worth, to meaning. You feel not only that you have lost something, but that you yourself are worth nothing.

In 2013, the American diagnostic manual DSM-5 removed the so-called bereavement exclusion. Previously, depression could not be diagnosed in the first weeks after a death, because it was attributed to grief. Today it is accepted that a loss can trigger genuine depression and that there is no need to wait for it to “pass on its own”. I explain the difference in more detail in Depression is not sadness: how to tell them apart and why it matters and After a major loss: when grief turns into depression. You will also find a short explanation of depression in the knowledge base.

Signs that make it worth seeking help: low mood or emptiness nearly every day for two weeks or more, loss of interest in everything that used to bring you joy, disturbed sleep and appetite, a sense of worthlessness or excessive guilt, difficulty concentrating. Depression is diagnosed by a doctor or psychiatrist, not by an article online. But if you recognise yourself in these descriptions, that is a good enough reason for a conversation.

The third sign: thoughts of death

After a loss it is entirely normal to think about death. “I want to be with him.” “What’s the point of anything now?” Thoughts like these are often an expression of longing and do not necessarily mean danger. But the line between longing and danger is not always clear — not even to the person themselves.

Research shows that the risk of suicide is higher in the period after a loss, especially after the death of a partner, after the suicide of someone close, and among men who have been left alone. It is also higher after losing a job and after divorce. I wrote about the particular burden of grief after suicide in Grief after a suicide.

If you are thinking about how you might take your own life, if you have a plan, or if it feels as though it would be better if you were not here, do not wait until next week. In Slovenia, call:

• The crisis line Klic v duševni stiski: 01 520 99 00 — every day from 7 pm to 7 am
• The Samarijan helpline: 116 123 — 24 hours a day, free of charge
• Emergency medical help: 112 — when life is in immediate danger

If you are worried about someone else, you may ask them directly: “Are you thinking about harming yourself?” Research has repeatedly shown that such a question does not plant the idea. It often brings relief, because the person can at last say what they have been carrying alone.

Other signs worth taking seriously

Beyond the three main signs, there are a few other circumstances in which help often proves useful:

• The loss was sudden or traumatic. An accident, violence, suicide, a dismissal with no warning. Then grief may be joined by intrusive memories, nightmares and a constant readiness for danger — signs described under post-traumatic stress disorder.
• The loss opened up something old. A breakup that awakens a childhood feeling of abandonment. The death of a parent with whom things were never resolved.
• Using alcohol, sedatives or other substances to get through the day.
• Relationships are falling apart. Partners drift apart over a shared loss, a family splits, children are left without support.
• The people around you are not helping, or are not there. If you have no one to talk to about what happened, a therapist can be the first place where you hear it said out loud.

In relational family therapy, in which I am training, we pay particular attention to the second point. Christian Gostečnik describes how a new loss often awakens old, unprocessed experiences — and how the feelings that belong to the old then spill over into a present relationship. In that case it is not enough simply to wait. We need to understand what has really been awakened.

(A composite conversation, not a real person.)
“I know it’s silly. My friend just moved away and stopped replying. It’s not a death.”
“No, it isn’t a death. But it is someone who is no longer where they used to be.”
“So why does it hurt so much? I sleep four hours a night. I can’t get anything done at work.”
“When have you felt like this before — that someone simply disappears and you don’t know why?”
“… When my father left. I was nine.”

Where to turn in Slovenia

Once you decide you need help, the next question is — where. In Slovenia there are several routes, and they do not exclude one another.

Your GP is often the first step. They can assess whether this is depression or a physical problem, prescribe medication if it is needed, and refer you to a psychiatrist or clinical psychologist. Some health centres also have adult mental health centres, where a team of professionals works together.

A psychiatrist makes sense when depression is more severe, when there are thoughts of suicide, or when medication might help you. Medication and psychotherapy do not rule each other out — I wrote about this in Antidepressants and therapy are not rivals.

Psychotherapy is appropriate when grief does not shift, when a loss has reopened old wounds, or when relationships are suffering. In marriage and family therapy you can come to sessions alone, with your partner or with your family, which is often valuable when a loss is shared.

Support groups can be a great source of strength, because in them you meet people with similar experiences. The Slovenian Hospice Association (Slovensko društvo Hospic) offers support to grieving adults and children, and the association Vrabček upanja supports parents who have lost a child.

Exercise: an honest review of the past month

After a loss, people often do not know whether their state is “bad enough” for help. This exercise can help you see more clearly. Take fifteen minutes and a sheet of paper.

1. Write down the loss and the date. When did it happen? How much time has passed? Also note any losses that came before or after it.
2. Rate the past month from 0 to 10 in five areas: sleep, food, work or school, relationships with the people close to you, and the things that used to bring you joy. 10 means “as before the loss”, 0 means “not at all”.
3. Compare it with the first month after the loss. Has anything shifted, even a little? Has it stayed the same, or got worse?
4. Answer one question honestly: In the past two weeks, have I ever thought it would be better if I were not here?
5. Show the page to someone you trust — or take it to your doctor. If your ratings are below 4 in several areas, if nothing is shifting, or if the answer to the fourth question is “yes”, that is a good enough reason to seek help.

This exercise is not a diagnostic test. It is a way of looking at your situation from the outside, as you would look at a friend’s. We are often far more honest with others than with ourselves.

When therapy is not the answer

I want to be honest in the other direction too. Professional help is not always needed, and it is not always useful.

In 2008, Joseph Currier, Robert Neimeyer and Jeffrey Berman reviewed dozens of studies on therapy for bereaved people. They found that interventions offered to all bereaved people, regardless of how they were coping, on average barely helped. They benefited mainly those who were already having marked difficulties with their grief. In other words: therapy is not a vaccine that everyone who has lost something should receive.

George Bonanno’s research has shown that resilience is the most common outcome after a loss. Many people grieve, cry, remember — and gradually return to life without ever sitting down with a therapist. This is not denial. It is a healthy course.

Nor can therapy replace what the loss has taken. It does not bring back the job, the health or the person. With losses that have practical consequences — unemployment, debt, illness — legal, social or medical help is often just as important. A therapist can help you carry the burden, but cannot remove it.

And finally: if you feel that what you mainly need is someone to listen, and you have such a person in your life, that may be enough. Professional help makes sense when that support is missing or is not enough.

What help after a loss looks like

People are often afraid of therapy because they think they will have to “relive everything”. In reality, working with loss is much more gradual. In the first sessions the focus is on calming the distress: getting you sleeping again, having someone who knows what is going on. Only then does space open up for the loss itself — for what was, what was never said, what hurts.

For complicated grief, specific programmes have proved effective in research, such as the therapy developed by Katherine Shear. For depression, cognitive behavioural approaches help, along with medication when needed. In relational family therapy we also work with relationships: how the loss has touched the partnership, the family and old wounds.

If you would like to know how my work runs in practice, you can read more on the Contact page. If it feels as though too many losses have built up lately, you may also find help in When everything comes at once: cumulative loss. A short explanation of crisis is in the knowledge base.

What to remember

• Most people come to terms with a loss without professional help — but roughly one in ten gets stuck.
• The three main signs are: grief that does not move, depression and thoughts of death.
• The signs apply to every loss — not only death, but also a breakup, a job, health or a home.
• If you have thoughts of suicide, call straight away. In Slovenia: 01 520 99 00, 116 123 or 112.
• The first step can be your GP; psychotherapy makes sense when grief gets stuck or reopens old wounds.