Summary and Keywords
Death and loss are universal human experiences, yet understandings of and attitudes toward expressing grief have shifted across time. The earliest psychological conceptualization of grief pathologized “holding on” to the lost object, a notion that has since been rejected in favor of a conception of continuing bonds that can be adaptive in grief. Similarly, early stage theories of grieving suggested a linear progression toward resolution and acceptance of loss, which has been criticized in favor of approaches that allow for natural regulatory processes of attending to the loss and reengaging with a changed world. In sum, grief is no longer regarded solely as looking back on a past life with the deceased but rather is oriented toward creating and reconstructing a meaningful present and future that accommodate the loss and its impact.
Most people respond adaptively to loss by relying on their internal and social support systems. However, a significant subset of grievers struggles with complicated grief, which is characterized by intense longing for the deceased, causes impairment in various life domains, and extends beyond the period of grieving that is considered normal for the population and culture. Grief therapy is most appropriate and advantageous for grievers who self-identify the need for additional support, and this tends to happen among those who are struggling disproportionately. Complicated grief shares features with other common psychiatric diagnoses (e.g., Major Depressive Disorder and Posttraumatic Stress Disorder), as well as being characterized by distinctive separation distress regarding the deceased. Treatment for complicated grief targets the common symptoms among these disorders as well as the grief-specific manifestations of distress that are concentrated on issues of coping, attachment, meaning, and behavior.
The Evolving Landscape of Grief
Death and loss are universal human experiences. Bereavement is an utterly ordinary, yet potentially profoundly impactful, experience. Though cultural and religious practices have long paid homage to the dead and provided an outlet for grief among the bereaved, understandings of and attitudes toward such practices have shifted across time. One such evolving understanding concerns the appropriateness of grief therapy: For whom is specialized grief therapy appropriate and necessary? In what form might grief therapy be delivered, and what research supports the selected approach? When should such interventions occur? Historical and contemporary perspectives on grief help to inform the answers to these questions, while recent research provides evidence regarding who is helped, when, and by what means.
In the Beginning: Freud and Letting Go
The first theorist to attempt to understand grief from a scientific perspective was Sigmund Freud, who published Mourning and Melancholia in 1917 (Freud, 1917/1957). Freud both normalized and pathologized grief. His theory of mourning postulated that the process of grieving was characterized by detaching from the lost “object.” Prior to this emotional disconnection or decathexis, the mourner would experience feelings of dejection, diminished interest in the surrounding world, and compromised capacity for love and meaningful activity. Once decathexis was reached, the mourner would in essence have let go of the lost object, permitting reengagement with the world and one’s inner capacities for productivity and enjoyment. This theory validated the challenge of bereavement and explained the prevalence of withdrawal and diminished capacity that often accompany acute grief. Freud also introduced a pathological view of mourning, melancholia, which was essentially a refusal to experience decathexis in favor of stubbornly clinging to the lost object. Holding on to the lost object was perceived as a denial of reality (Freud, 1917/1957) and thus problematic. The Freudian notion of “letting go” of the loss infiltrated ideas about bereavement for the rest of the 20th century. Most contemporary theories integrate the concept in some fashion, though with radically different goals and implications.
Stage Theory: Moving Toward Acceptance
The next popular contribution that shaped the landscape of grief was Elisabeth Kübler-Ross’s (1969) book, On Death and Dying. Just as Freud’s perspective on melancholia emphasized resistance to the reality of the loss, Kübler-Ross’s theoretical stages of dying began with denial. Subsequent stages included anger, bargaining, depression, and acceptance (Kübler-Ross, 1969). These stages were derived from unstructured interviews with terminally ill patients and suggest a linear progression through the grieving process, although Kübler-Ross herself was explicit that people’s movement through the various stages could be idiosyncratic and repetitive. Stage theory nonetheless was often taken to offer emotional landmarks to indicate progress on the journey toward acceptance, whether of one’s own death, or that of another. While this formulation implies a certain predictability in grieving and prioritizes emotion, it gives scant attention to two of the major foci of psychological interventions in the present day: cognitions and behavior. However the major criticism of Kübler-Ross’s stage theory is that the presumed endpoint of resolution, acceptance, is often present for bereaved people in the earliest weeks of bereavement, rather than after working through the prior stages. This is especially true for grievers who experience natural death losses, though it is less often the case in instances of sudden or violent death (Holland & Neimeyer, 2010). Ultimately, critiques of both Freudian and stage models gave rise to contemporary theories of bereavement emphasizing behavioral, affective, cognitive, social, and existential/meaning-oriented perspectives.
The Dual Process Model: A Question of Balance
In contrast to the formulations of grief described above, the Dual Process Model of Bereavement posits an iterative process of oscillating between loss-oriented coping and restoration-oriented coping (Stroebe & Schut, 1999, 2010). In the former, the bereaved engage the emotions and circumstances of the loss, yearning and longing for the deceased, giving attention to the relationship and attempting psychologically to relocate the deceased in their lives. In attending to the grief, loss-oriented coping allows the mourner temporarily to ignore the call of a world fundamentally changed by the death. Restoration-oriented coping, by contrast, occurs as mourners divert attention to the demands of living, seeking respite from grief through engaging people and projects, and ultimately adapting to new roles, expectations, and opportunities. Understandably, these orientations do not occur in simple succession. By oscillating repeatedly between the loss and restoration orientations, grievers eventually are able to modulate, as needed, the pain of the loss and the pain of a changed life. This reflects a natural, self-regulatory capacity for adaptation to distress. During the acute phase of grief, it is natural for grievers to engage in more loss-oriented coping, with progressively greater attention to restoration as they move forward. In the terminology of this model, grief could be complicated by a flight toward restoration that avoided processing the loss, by a prolonged preoccupation with the loss and minimal engagement with restoration, or with difficulty oscillating between orientations.
The Two-Track Model: Assessing Continuing Bonds
Another contemporary perspective on bereavement pays particular attention to the attachment relationship with the deceased person. As recognized in the work of John Bowlby (1980), the death of a loved one who once provided a secure base from which to explore the world can challenge the mourner’s emotional and relational stability. Research suggests that people’s attachment style can affect their bereavement trajectory. For example, older widows and widowers who were highly dependent on their spouses before death may struggle disproportionately in the early years following bereavement (Bonanno, Wortman, & Nesse, 2004). By contrast, highly independent individuals tend to exhibit less distress following loss, particularly if the loss is natural or expected (Meier, Carr, Currier, & Neimeyer, 2013).
The Two-Track Model of Bereavement (TTMB) pays attention to these varying outcomes and includes a focus on how the mourner manages the ongoing relationship with the deceased following the death. The prospect of continuing a bond with the deceased is therefore considered a normal, and even desired, response to loss (Rubin, 1999). Attending to the relationship with the deceased, as it evolves through the course of bereavement, is one of the TTMB’s tracks. It includes ways in which the mourner continues to remember, speak about, find inspiration in, or avoid a sense of ongoing connection to the loved one. The other track, which sometimes runs parallel to and other times intersects with the former, attends to the griever’s biospychosocial functioning. This includes many of the domains representative of acute grief, including changes in mood, social interactions, physical health, and work functioning (Rubin, 1999). Each track focuses attention on a distinct area of concern during bereavement, yet changes in one can contribute to shifts in the other. The Two-Track Model of Bereavement Questionnaire was specifically developed to help clinicians and researchers assess the trajectory of both tracks, noting their convergence and divergence, as well as a third track that attends to traumatic responses to loss (Rubin et al., 2009).
Meaning Reconstruction: Rebuilding the World
From the standpoint of a meaning reconstruction approach, a central process of grieving is the attempt to reaffirm or reconstruct a world of meaning that has been challenged by loss (Neimeyer, 2002). As formulated by Robert Neimeyer and his associates, the death of a loved one is seen as posing two narrative challenges to the survivor: (1) to process the event story of the death in an effort to “make sense” of what has happened and its implications for the survivor’s ongoing life, and (2) to access the back story of the relationship with the loved one as a means of reconstructing a continuing bond or addressing unfinished business in the relationship (Neimeyer, 2016). In a sense, then, the bereaved are prompted by unwelcome change associated with the death to “rewrite” important parts of their life story to accommodate the event of the loved one’s dying, and to project themselves into a changed future, one that ideally retains a measure of continuity with the “back story” of a past shared with the loved one. Such an emphasis is consonant with the narrative therapy approach to bereavement support championed by Lorraine Hedtke (2012).
A good deal of research has demonstrated a link between an inability to find meaning (whether spiritual or secular) in the loss and intense, prolonged grief in groups as varied as family members of patients in palliative care (Burke et al., 2015), bereaved young people, parents, older adults and survivors of homicide, suicide and other violent deaths (Neimeyer, 2014). Conversely, ability to make sense of the loss has been found prospectively to predict higher levels of well-being among widowed persons (e.g., interest, excitement, accomplishment) one to four years later (Coleman & Neimeyer, 2010), and success over time in integrating the loss into one’s meaning system is associated with a significant reduction in complicated grief symptomatology (Holland, Currier, Coleman, & Neimeyer, 2010). Several measures of meaning making in bereavement have been constructed and validated (Neimeyer, 2016), contributing to a toolbox of instruments for conducting clinical assessment and tracing change processes in grief therapy. Likewise, numerous narrative and meaning-oriented techniques for fostering reconstruction in bereavement are beginning to be evaluated in both open and controlled trials by a wide network of investigators (Neimeyer, 2016).
Most research on bereavement outcomes has used exclusively post-loss measures of functioning, as participants are recruited into the research only once the death has occurred. To capture more of the nuances of pre-loss experiences and conditions, Bonanno and colleagues (2002) investigated bereavement trajectories for spouses, beginning months or years before the loss and extending to 18 months post-loss. Based on pre- and post-loss measures of depression, their findings suggest that many grievers (46%) follow a resilient course (low depression at all time points). Indeed, such mourners rely on their own resilience and that of their families and communities in response to loss, and there is little evidence that specialized assistance would further aid their adaptation on the criterion of loss alone (Currier, Neimeyer, & Berman, 2008). However, some grievers may elect to take advantage of grief support, and it certainly should be offered to those who seek it.
The next largest group was chronic grievers (16%), who displayed low levels of depression pre-loss but sustained high levels at 6 and 18 months post-loss (Bonanno et al., 2002). Exploring differences between these groups, which is supported by other research on risk factors for complicated grief (e.g., Burke & Neimeyer, 2013), directs attention to those who may be most in need of grief therapy. Groups that are considered “high-risk” include parents who have lost children and survivors of violent loss (e.g., homicide or suicide), among others. Individuals who have suffered these types of losses are more likely to experience distress in adapting to bereavement, and research suggests that grief therapy is most appropriate and advantageous for bereaved people with clinically significant levels of distress that endure for a considerable period of time (Currier et al., 2008; Neimeyer & Currier, 2009). More generally, adaptation to loss is a highly individualized experience, influenced by many factors within and beyond the bereaved person. For example, Doka and Martin (2010) theorize that gender norms, family history, and personal coping styles converge to shape distinctive grieving styles, such as those they label intuitive (emotion focused and expressive) and instrumental (more practical, stoic, and cognitive). Although no single style of grieving has been found to lead to reliably better outcomes than others, it is important to recognize that any loss has the potential to result in complicated or prolonged grief, and therapy is appropriate for helping those whose adaptation is particularly problematic.
Complicated Grief and Prolonged Grief Disorder
The chronic grievers in Bonanno’s study (2002) may also be known as complicated grievers. Complicated grief (CG), or prolonged grief disorder (Prigerson et al., 2009), is a condition affecting a small but significant subset of grievers, causing impairment in various life domains and extending beyond the period of grieving that is considered normal for the population and culture. It disproportionately affects women over the age of 60 (Kersting, Brähler, Glaesmer, & Wagner, 2011) and is more likely when the death is sudden or violent (e.g., homicide, suicide, or fatal accident). CG is protracted, with intense yearning or longing for the deceased, is often accompanied by intrusive thoughts of the deceased, and may include a sense of disbelief about the reality of the loss (Shear, 2015). As evidence continues to build for the severity and distinctiveness of prolonged grief disorder, it has been included in the World Health Organization’s International Classification of Disease, 11th edition (ICD-11). As research documents that mortality risk increases with CG (Szanto et al., 2006), a variety of specific treatments have been developed that show promise for mitigating the distress associated with this condition, as addressed in the remaining sections of this article.
Cognitive Behavioral Therapy (CBT)
Though complicated grief is distinguished from other mental health issues by the presence of intense yearning for the deceased or preoccupation with the death, other aspects of CG are similar to prominent psychiatric diagnoses such as Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). Like MDD, CG can result in psychomotor retardation, guilt, loss of interest, and sleep and appetite disturbance (Shear & Mulhare, 2008). Similarly, like PTSD, CG often includes a sense of helplessness, intrusive images, and avoidance (Shear & Mulhare, 2008).
Complicated grief treatment from a cognitive-behavioral perspective generally addresses three major areas of impairment: avoidance of bereavement-related stimuli (addressing the overlap in PTSD symptoms), negative cognitions resulting from the loss (addressing overlap in both PTSD and depressive symptoms, e.g., rumination), and social and emotional withdrawal (addressing overlap in depressive symptoms) (Eisma et al., 2015). Avoidance of bereavement-related stimuli is thought to maintain complicated grief symptoms by preventing confrontation and eventual integration of aspects of the loss into the griever’s new reality. Overcoming avoidance involves an emotional engagement in the reality of the loss that may be frightening or overwhelming to grievers, hence the reason for avoidance in the first place. With its roots in treating anxieties of many kinds, exposure gradually introduces or reintroduces the aversive stimuli of the loss while promoting emotion modulation.
Sometimes avoidance is motivated not by anxiety or fear but by disengagement and lack of interest, a more depressive manifestation. Distinct from the intentional avoidance that characterizes the PTSD type, withdrawal avoidance can be understood as being more passive. This maintains CG symptoms by widening the gap between life before the loss, when relationships and activities felt more rewarding, and life after the loss, when a sense of direction and purpose feel stripped away. This type of withdrawal is better challenged by a behavioral activation approach, which seeks to increase positive interactions with others and the world.
Negative cognitions resulting from the loss maintain CG by altering the way grievers see themselves, others, and the world in the aftermath of loss. From concrete concerns of daily living (e.g., “I don’t know how I will ever take care of myself now that she’s gone”) to more global negative appraisals (e.g., “I can never be happy again without him”), changes in cognitions can exacerbate anxiety, fear, confusion, and depression.
From a cognitive-behavioral perspective, the most widely supported approaches to addressing the problems of avoidance, withdrawal, and negative alterations in cognitions are exposure, behavioral activation, and cognitive restructuring, respectively. All of these approaches have received research support among complicated grievers. Boelen, de Keijser, van den Hout, and van den Bout (2007) compared sequences of (1) cognitive restructuring followed by exposure (6 sessions of each), (2) exposure followed by cognitive restructuring (6 sessions of each), and (3) 12 sessions of nonspecific supportive counseling for treating CG. The cognitive-behavioral interventions led to greater improvement than supportive counseling, and exposure was more efficacious on its own and when supplemented by cognitive restructuring than either cognitive restructuring on its own or when supplemented by exposure. These findings were supported by Bryant and colleagues (2014), who conducted a CBT intervention with and without an exposure component and found that CBT plus exposure led to greater reductions in CG, depression, negative appraisals, and functional impairment. These findings suggest that helping grievers confront and work through the loss, rather than focusing exclusively on cognitions, is important for complicated grievers.
Papa, Sewell, Garrison-Diehn, and Rummel (2013) examined the impact of 12–14 sessions of behavioral activation (BA) compared to no treatment (in a delayed start group) and found reductions in CG, PTSD symptoms, and depression symptoms. With growing evidence for exposure and behavioral activation, Eisma and colleagues (2015) compared these interventions to a waitlist control group and found that both treatment groups showed decreases in CG, posttraumatic stress, and grief rumination, while the exposure group also showed decreases in depression and brooding. Overall, cognitive-behavioral interventions have been shown to decrease distressing symptoms across comorbid psychiatric problems, although evidence is less clear for the durability of treatment effects and the role played by investigator allegiance in accounting for positive findings (Currier, Holland, & Neimeyer, 2010).
Complicated Grief Treatment (CGT)
Despite the similarities between bereavement distress and MDD and PTSD, there are important differences that warrant targeted intervention. Rather than the pervasive sadness and diminished experience of MDD, complicated grievers experience sadness specifically related to the loss, while maintaining interest in the deceased. In CG, ruminative thoughts and feelings of guilt are often focused on the person who died and the circumstances of the death. Meanwhile, the primary emotional experience of PTSD, fear, is replaced by sadness in CG. While cognitive-behavioral interventions have some demonstrated efficacy with these comorbid psychiatric problems, they may not adequately focus the unique aspects of the bereavement experience, especially when that experience is prolonged beyond the stage of acute grief. To address this gap, Shear and colleagues developed a targeted intervention for complicated grief, which derives from an attachment-based perspective on bereavement.
While a review of attachment theory and its relevance to understanding bereavement is beyond the scope of this article, there are a few broad areas of impact that form the scaffolding for the work of CGT through this frame. First, the loss of a loved one activates a proximity-seeking desire (Shear & Shair, 2005) that is an innate part of being human. Preoccupation with the deceased can be understood as an intrinsically motivated desire to be close to the attachment figure for all the comfort and protection provided by that closeness. Second, the internal working model provided by an attachment figure serves a regulating function, through an internalized representation of a person who is physically available and also emotionally responsive (Shear & Shair, 2005). When loss occurs, that regulatory function is compromised, which contributes to upheaval of physiological and emotional processes in the midst of intense longing for the deceased (Shear et al., 2007). Withdrawal and diminished interest can be understood as retreating into oneself out of uncertainty that one can function without the attachment figure (Shear, Boelen, & Neimeyer, 2011). Finally, since the attachment system is supposed to be a source of stability and strength in an unfamiliar and sometimes threatening world, it is logical that a bereaved person would seek connection with an attachment figure, even if that person were not tangibly present. The deceased person becomes both the source of and the antidote to the distressing emotional experience of separation. It is easy to imagine how CG develops out of this painful tug of war between hope and reality.
Shear and colleagues developed a 16-session manualized treatment, complicated grief treatment (CGT), to address the symptoms of complicated grief and help the griever return to a mourning process that naturally resolves itself in time (Shear et al., 2011). The principles guiding this approach include promoting oscillation between loss and restoration orientations (see the previous discussion of the Dual Process Model of Bereavement); eliminating behavioral, cognitive, affective, and social problems through appropriate interventions (e.g., decreasing avoidance and/or promoting adaptive avoidance) (Shear, 2010); enhancing autonomy through positive emotionality, problem solving, and by increasing motivation; and envisioning a future that is satisfying and joyful (Shear et al., 2011). The 16 sessions are divided into introductory, middle, and termination phases that broadly follow the arc of the guiding principles. Specific interventions include psychoeducation, imaginal exercises for revisiting the death, imaginal conversations for interacting with the deceased, and working on personal goals.
This treatment, in its original form and with some adaptations, has been empirically tested and shown to be efficacious. Shear and colleagues’ initial randomized controlled trial compared CGT to interpersonal psychotherapy (IPT), which is a demonstrated effective treatment for depression. CGT was significantly more effective than IPT (Shear, Frank, Houck, & Reynolds, 2005). Clinically significant change was again found when comparing CGT to IPT among elderly people (Shear et al., 2014). Supiano and Luptak (2014) adapted CGT to a group format and compared it to a treatment-as-usual group in another randomized controlled trial. While both groups demonstrated statistically significant improvement, the CGT group improved significantly more. While the sample size was small and the study considered a pilot, the results further support the efficacy of CGT as a targeted intervention for CG. The therapeutic elements of CGT, carefully selected based on current understanding of CG, appear to promote positive adaptation to loss among grievers whose journeys had been previously difficult and challenging.
Grief therapy is most warranted and effective when the griever asks for it and when the loss is complicated. While there is variability in theoretical conceptualizations of the grieving process as well as empirical support for diverse approaches to treatment, there are some common threads that seem to be woven throughout, which concentrate on issues of coping, attachment, meaning and behavior. These are elucidated by Shear and colleagues (2011, pp. 158–159), who noted several convergent themes across their respective approaches: (1) confrontation with the story of the death through exposure to the most difficult aspects of the loss in service of integrating the experience into the grievers’ beliefs about themselves and the world; (2) engaging with the image, voice, or memory of the deceased to facilitate a sense of ongoing attachment that both maintains the relationship with the deceased and also allows for other relationships to be built and strengthened; (3) challenging avoidance coping through promoting emotion regulation skills; and (4) encouraging the bereaved to review and revise life goals and roles in a world without the deceased person. Although there is variability in the ways these therapeutic goals are met, these objectives appear to underpin several treatments that are uniquely suited to address complicated grief.
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