Grief Counseling
Treating Complicated Grief
• Avi Kriechman, M.D.
• UNM Department of Psychiatry and Behavioral Sciences
• Division of Community Behavioral Health
Objectives
• Describe and utilize guidelines for the differential diagnosis of grief
reactions
• Describe complicated grief and the variety of ways in which it presents
in clinical practice to enhance practitioner skill in assessing
complicated grief in everyday practice
• Describe and utilize guidelines for treatments specifically targeted to
address complicated grief reactions to enhance patient health status
through appropriate referrals and practice
Bereavement Grief Mourning
Bereavement: the experience of losing a loved one to death. The time
spent in bereavement depends on how attached the person was to the
person who died, and how much time was spent anticipating the loss
Grief: the normal and natural psychological, emotional, physiological,
social and cultural reactions to losing a loved one (or other kinds of
loss and change)
Mourning: showing grief in public, affected by personal and family
beliefs, religious practices, and cultural customs and rituals.
Types of Grief
Normal: the normal and natural psychological, emotional, physiological, social
and cultural reactions to losing a loved one (or other kinds of loss & change)
Anticipatory: may occur when a death is expected but before it happens; may
help bereaved but not help the dying person; does not always occur
Disenfranchised: grief not acknowledged by society:
loss of stigmatized/hidden/discounted relationship, pregnancy (abortion,
miscarriage), pet, job, home, etc.
Complicated/Prolonged
[briefly named Traumatic Grief, but renamed because of confusion with Traumatic
Bereavement - loss due to violent causes- and PTSD]
Normal Grief
Physical expressions of grief often include crying and sighing, headaches, loss
of appetite, difficulty sleeping, weakness, fatigue, feelings of heaviness, aches,
pains, and other stress-related ailments.
Emotional expressions of grief may include feelings of sadness & yearning,
worry, anxiety, frustration, anger, or guilt.
Social expressions of grief may include feeling detached or disconnected from
others & isolating from social contact
Spiritual expressions of grief may include questioning the reason for your loss,
the purpose of pain and suffering, the purpose of life, and the meaning of
death.
Little Evidence Grief Counseling Needed in
Normal Grief
“….many bereaved individuals will exhibit little or no grief…these individuals are not cold
and unfeeling or lacking in attachment but, rather, are capable of genuine resilience in
the face of loss. Almost half of the participants in this study (46% of the sample) had low
levels of depression, both prior to the loss and through 18 months of bereavement, and
had relatively few grief symptoms (e.g., intense yearning for the spouse) during
bereavement. An examination of the prebereavement functioning of this group revealed
no signs of maladjustment… They did, however, have relatively high scores on several
prebereavement measures suggestive of the ability to adapt well to loss (e.g., acceptance
of death, belief in a just world, instrumental support).”
“How many of the bereaved individuals who do not exhibit overt grief reactions will
eventually develop delayed grief reactions? The evidence is unequivocal on this point: No
empirical study has ever clearly demonstrated the existence of delayed grief.”
Bonanno, G. A. (2004). Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after
extremely aversive events?. American psychologist, 59(1), 20.
Little Evidence Grief Counseling Helpful in Normal
Grief
“Grief interventions are further complicated by the belief held by most
service providers that their interventions are efficacious…However,
research has demonstrated that grief interventions for those with
“normal” grief show little to no effect, and in a high proportion of cases,
the bereaved participants would have been better off without the
intervention.”
Breen, L. J., & O'Connor, M. (2007). The fundamental paradox in the grief literature: A critical
reflection. OMEGA-Journal of Death and Dying, 55(3), 199-218.
Who Needs Grief Counseling?
Gamino et al. : 3 clusters of non-clinical grievers whose loved ones died
between 12-40 months prior to the study.
High Growth (largest group)
Low Impact Grievers (2nd largest group)
High Grief: (smallest group)
Who Needs Grief Counseling?
High Grief: (smallest group)
Highest levels of distress
Least adaptive (pessimistic, less social support, didn’t find mourning
rituals comforting)
More likely to have lost loved one through suicide or homicide
Most often sought grief counseling
Diagnosing Complicated Grief
Unusually severe and prolonged grief that significantly
impairs function that is more likely
after the loss of a child or life partner
after a sudden death by violent means
after discovering the body of the deceased
if high levels of pre-loss insecure attachment and dependency and/or
low levels of social support
if pre-existing anxiety, stress and/or depressive disorders pre-loss
Complicated Grief
Clinical Features
Acute grief symptoms that persist for more than six months
following the death of a loved one, including:
Feelings of intense yearning or longing for the person who died – missing the person so much it’s
hard to care about anything else
Preoccupying memories, thoughts or images of the deceased person, that may be wanted or
unwanted, that interfere with the ability to engage in meaningful activities or relationships with
significant others; may include compulsively seeking proximity to the deceased person through
pictures, keepsakes, possessions or other items associated with the loved one
Recurrent painful emotions related to the death, such as deep relentless sadness, guilt, envy,
bitterness or anger, that are difficult to control
Avoidance of situations, people or places that trigger painful emotions or preoccupying thoughts
related to the death
Difficulty restoring the capacity for meaningful positive emotions through a sense of purpose in life
or through satisfaction, joy or happiness in activities or relationships with others
Complicated Grief
Depression & PTSD
Comparing rates in elderly grievers,
• only 7.4% suffered from complicated grief (Maercker et al. 2005)
• 16% to 24% from major depression (Shuchter & Zisook 1993)
• and 20% to 31% from PTSD (Schut et al. 1991)
Complicated Grief vs. Depression
• Sadness related to missing deceased vs. pervasive sadness
• Interest in memories of deceased, longing and yearning for
contact, pleasurable reveries vs. pervasive anhedonia
• Guilt focused on interactions with deceased vs. pervasive guilt
• Preoccupation with positive thoughts of deceased vs. rumination
about past failures or misdeeds
• Intrusive images of person dying & avoidance of reminders of
loss (situations & people) vs. not prominent in depression
Complicated Grief vs. PTSD
Triggered by loss vs. physical threat/trauma
Primary emotion is sadness vs. fear
Nightmares rare vs. common
Painful reminders more pervasive and unexpected vs. most often
linked/specific to traumatic event
Yearning & longing for deceased and pleasurable reveries not
prominent in PTSD
Why It’s Important to Diagnose Complicated Grief
Randomized, controlled trials provide support for the
efficacy of a targeted psychotherapy for complicated grief
that provides an explanation of this condition, along with
strategies for accepting the loss and for restoring a sense of
the possibility of future happiness.
Complicated Grief Treatment
Complicated Grief Treatment developed by Shears et al. is currently the
only evidence-based model specifically designed to ameliorate the
symptoms of Complicated Grief.
Integrates strategies from Interpersonal Psychotherapy, Cognitive
Behavioral Treatment for PTSD, and Motivational Interviewing to
include both loss-related and restoration-related strategies
Typically as 16 sessions over a 4 month period
Restoration-related activities continue in parallel with loss-focused
interventions.
Complicated Grief Treatment Format
Each session is structured, with an agenda that includes reviewing the
previous week’s activities, doing work in session, and assigning tasks
for the coming week.
Sessions 1-3: establish a strong therapeutic alliance, obtain a history of
the client’s interpersonal relationships, provide psychoeducation about
the model of complicated grief, and describe the elements of
treatment. A supportive person usually attends the third session.
Sessions 4 to 9, bereaved performs exercises inside and outside of the
session to come to terms with the loss and address restoration of the
capacity for joy and satisfaction in life.
Final sessions 10 to 16, the therapist and bereaved review progress and
collaboratively decide how best to complete the work and consolidate
treatment gains. This part of treatment may resemble Interpersonal
Psychotherapy.
Why It’s Important to Diagnose Complicated Grief
Randomized, controlled trials provide support for the
efficacy of a targeted psychotherapy for complicated grief
that provides an explanation of this condition, along with
strategies for accepting the loss and for restoring a sense of
the possibility of future happiness.
Therapeutic Targets of
Complicated Grief Treatment
Most bereaved balance grief-related thoughts (separation anxiety,
bitter protest, sadness, self-blame) with greater acceptance of &
optimism for the new reality. Those with complicated grief have
trouble doing so.
People with Complicated Grief often excessively avoid painful
situations or compulsively seek proximity with and dependency on
others.
People with Complicated Grief experience loss-focused attention that’s
intensely painful and infused with deep longing, while their
restoration-focused attention is associated with a sense of disbelief &
protest with little sense of purpose, joy or satisfaction.
Overall Framework of
Complicated Grief Treatment
Information about grief, CG and CGT
Use of a grief monitoring diary
Involvement of a significant other
Facilitation of optimal interpersonal functioning
Work on personal goals and self care
Revisiting the story of the death, its implications and consequences
Revisiting places and activities that are avoided
Working with memories, pictures, and
Imaginal conversation with the deceased.
Psychological impediments to grief progress are identified and
targeted, including thoughts, feelings and behaviors that activate the
attachment system and/or impede its deactivation.
Imaginal Revisiting
Bereaved verbally recounts story of death to face aspects of the event that
prevent acceptance.
A brief exercise intended to facilitate ability both to think about the death and
to set it aside. This is done to facilitate the establishment of an effective rhythm
of oscillating attention toward and away from the painful reality of the death.
Extensive debriefing of the revisiting exercise with focus on identifying
problematic beliefs that are sticking points in processing the loss.
Bereaved person both reporter and observer in retelling the story of the death.
Visual exercise at end of debriefing period to help the person imagine how they
might ‘put the story away’.
Imaginal Conversation between griever & deceased to address issues such as
guilt, ambivalence, etc.
Restoration-Related Activities
Personal Goals Work via Motivational Interviewing
Re-envision future by identifying practical, long-term goals that create
a sense of interest, excitement & possibility of personal fulfillment
Invite bereaved to consider what she or he would want to do if grief was
at a level where it no longer interfered with their life
Enhance Self Care
Involvement of significant other
Optimize relationship functioning: Interpersonal Psychotherapy
strategies to
Support the bereaved person’s current close relationships
Encourage pleasurable and satisfying social relationships
Help problem solve any relationship difficulties.
Grief Monitoring Diary
The grief monitoring diary includes daily ratings of the person’s highest
and lowest level of grief, with a brief note indicating the situation in
which this occurred and a rating of the average level of grief for the day.
These ratings are used to help the person see that grief fluctuates
naturally.
Help bereaved recognize situations associated with high and low levels
of grief so they feel less out of control.
The average levels provide a rough estimate of reduction in overall grief
intensity in response to treatment.
Summary of CGT Strategies
Loss Focus
Imaginal revisiting & debriefing
Imaginal conversation with the deceased
Working with memories & pictures
Summary of CGT Strategies
Restoration Focus
Restoration Focus
Personal goals & self-care
Involvement of significant other
Optimize relationship functioning
Summary of CGT Strategies
Both Loss & Restoration Focus
Provide information on complicated grief & complicated grief
treatment
Instill hope
Grief monitoring diary
Situational revisiting: counselor challenges behaviors & cognitions that
reinforce bereaved’s avoidance of people, places, situations, & activities
that were once enjoyed but now trigger bereavement-related distress
following the loss.
Why It’s Important to Diagnose Complicated Grief
Randomized, controlled trials provide support for the
efficacy of a targeted psychotherapy for complicated grief
that provides an explanation of this condition, along with
strategies for accepting the loss and for restoring a sense of
the possibility of future happiness.
Objectives
• Describe and utilize guidelines for the differential diagnosis of grief
reactions
• Describe complicated grief and the variety of ways in which it presents
in clinical practice to enhance practitioner skill in assessing
complicated grief in everyday practice
• Describe and utilize guidelines for treatments specifically targeted to
address complicated grief reactions to enhance patient health status
through appropriate referrals and practice
Selected References
Bonanno, G. A. (2004). Loss, trauma, and human resilience: have we
underestimated the human capacity to thrive after extremely aversive
events?. American psychologist, 59(1), 20.
Bonanno, G.A. & Lilienfeld, S.O. (2008). Let’s be realistic: When grief
counseling is effective and when it’s not. Professional Psychology:
Research and Practice, 39 (3), 377.
Breen, L.J., & O’Connor, M. (2007). The fundamental paradox in the
grief literature: A critical reflection. OMEGA-Journal of Death and
Dying, 55(3), 199-218.
Crunk, A. E., Burke, L. A., & Robinson, E. H. (2017). Complicated grief:
an evolving theoretical landscape. Journal of Counseling &
Development, 95(2), 226-233.
Selected References
Currier, J. M., Neimeyer, R. A., & Berman, J. S. (2008). The effectiveness of
psychotherapeutic interventions for bereaved persons: A comprehensive
quantitative review. Psychological Bulletin, 134, 648−661.
Gamino et al. (2010). Who needs grief counseling? A report from the Scott &
White grief study OMEGA-Journal of Death and Dying, 60 (3), 199-223.
Jordan, J.R., & Neimeyer, R.A. (2003). Does grief counseling work? Death
Studies, 27, 765-786
Shear, M. K. (2010). Complicated grief treatment: The theory, practice and
outcomes. Bereavement Care, 29(3), 10-14.
Selected References
Shear, M. K. (2015). Complicated Grief. New England Journal of Medicine,
372(2), 153-160.
Turret, N., & Shear, M. K. (2012). Grief monitoring diary. In R. A.
Neimeyer (Ed.), Techniques of grief therapy: Creative practices for
counseling the bereaved (pp. 27–29). New York, NY: Routledge.
Wetherell, J. L. (2012). Complicated grief therapy as a new treatment
approach. Dialogues in clinical neuroscience, 14(2), 159.
Wittouck, C., Van Autreve, S., De Jaegere, E., Portzky, G., & van Heeringen, K.
(2011). The prevention and treatment of complicated grief: A meta-
analysis. Clinical psychology review, 31(1), 69-78.
