Complicated Grief Therapy

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Complicated Grief Therapy:  A Lifeline Back to Health, Hope and Happiness

Complicated grief, also known as prolonged, chronic, or traumatic grief, is a serious road block to mental health and happiness. This article provides an overview of chronic grief therapies as a unique and crucial approach to helping clients recover from ‘the pain that won’t go away.’  My research for the article draws heavily on the work of John R. Jordan, PhD, a clinical psychologist and grief counselor who specializes in working with survivors of suicide, and provides training for mental health professionals worldwide.  Dr. Jordan has authored numerous publications, training programs and manuals in the bereavement field, and was the recipient of the Association for Death Education and Counseling Research Recognition Award in 2006.

Normal vs. Chronic Grief?  What’s the Difference?

Grief is a normal and necessary, though painful, response to losing someone or something we love and treasure. Normal grief involves acute feelings of psychological pain in response to the loss of a loved one through death, the end of a relationship, termination of a job, or declining health. Grief can also stem from socially unrecognized or “disenfranchised” losses such as early miscarriage, loss of a same sex partner, death of a friend, addiction, caregiver grief due to chronic or terminal illness of a loved one, exiting a cult or being shunned by an authoritarian religious community, crime victimization, estrangement from one’s family of origin, and childhood abuse. The common denominator is that people grieve in direct proportion to the meaning the loss has for them.

Feelings of intense pain are common in normal grief, and can last from days to months.  Although every person grieves in their own unique way, grief has some common features including temporary preoccupation with the loss, sadness, fear, loneliness and disorientation. Most people recover from this intense pain over time, though memories of loss remain as permanent features of one’s psychological landscape.

Normal grieving involves a repeated fluctuation between a loss orientation, where a person moves towards grief, and a restoration orientation, in which grief is compartmentalized, and includes features of healthy avoidance. According to this framework, healthy grieving tends to be more voluntary, mindful and chosen (Jordan, 2011).

How well we cope with grief will determine our emotional resilience and ability to rebound from the pain of loss. According to William Worden (1992), there are four main tasks of healthy grief recovery: 

1. Accepting the reality of the loss;
2. Working through the pain and complexity of grief;
3. Adjusting to an environment in which the important person, place, activity, relationship, etc. is missing;
4. Moving away from grief and longing for what is lost, and finding a place for it in our memories as we move on with life

Most individuals going through ‘normal’ grief don’t require counseling to complete these grief recovery tasks. Healing tends to happen organically over time, especially with good support. However, many mental health professionals acknowledge that adequate familial and social support systems can be lacking for grievers, especially after the first few months following the loss. They also often agree that people experiencing healthy grief can still receive valuable help, understanding and normalization of grief emotions by engaging in counseling.

Grief counseling ceases to be an option that can enhance the natural healing process and instead becomes an essential lifeline in situations where the grief is chronic. Chronic grief is characterized by the lack of resolution or the intensification of acute grief symptoms such as disbelief, shock, anxiety or depression after more than six months to a year since the loss.[1]

Chronic grief is distinguished from ‘normal’ grief by feelings of hopelessness, loss of meaning and/or belief systems, intense pre-occupation and longing for a lost loved one or situation, apathy, a lingering sense of disbelief about the loss, avoidance of situations or thoughts that are reminders of the loss, and sometimes, distressing, intrusive thoughts related to the loss that are reminiscent of trauma symptoms. Left untreated, chronic grief can lead to severe clinical depression, substance abuse and at worst, suicidal ideation.

According to grief and trauma Psychologist John Jordan (2011), prolonged grief is experienced by approximately 15% of all grieving people, especially those who have been impacted by unexpected and/or traumatic loss, such as sudden death, protracted fatal illness, violence or catastrophic injury.

People who have a history of mental health concerns, substance abuse, childhood abuse, neglect or trauma are more vulnerable to chronic grief. Other risk factors include a poor sense of self-efficacy, low self worth, a high degree of dependency on the relationship or situation, perception that the loss was preventable, absence of social support, current stressors and secondary losses (e.g. money, social status). It has also been my experience that people who go through socially unrecognized grief can be at greater risk of chronic grief, as they feel isolated and stigmatized for ‘inappropriate’ grief. At any rate, the higher the degree of risk factors, the higher the need for individual therapy. And in the case of traumatic loss there is often a longer recovery trajectory.

Psychotherapy is particularly critical for recovery from chronic grief, and requires specific counseling approaches designed to treat grief, emotional and cognitive distress and trauma symptoms. Complicated grief has come to be understood as an Attachment Disorder, due to intense separation pain and anxiety stemming from the loss of an important person or object. Those suffering from complicated grief must learn to grieve the loss of important attachment figures in a healthier way. This involves acquiring the skill of being able to move towards or turn away from grief at will; skills that are present in healthy grievers. The experience of overcoming chronic grief also entails learning to manage internal emotional reactivity and coping with other people’s reactions to the loss, which may range from being distant to overbearing. Healing requires reforming one’s identity in the face of the loss and, sometimes, increasing life management skills, such as learning how to cook or drive (Jordan, 2011).

Existentially, healthy grief is a process of reconstructing meaning that occurs after our client’s world view and belief systems have been disturbed or violated by their loss. An important task of psychotherapy is to help our clients to rebuild meaning in a way that incorporates the loss in a constructive manner.

Treatment Interventions

John Jordan (2011) identifies four phases of prolonged grief recovery:

1. Reactive;
2. Reflective;
3. Integrative; and
4. Reintegration

The tasks of therapy and the role of the therapist shift according to the developmental needs of each phase. With regards to the type of counseling required and sequencing, according to Jordan, prolonged grief therapy should proceed as follows:

Step 1 – Crisis Therapy, which corresponds to the “Reactive” phase of grief;

Step 2 – Grief Therapy, which can overlap with the “Reactive” phase, once the crisis has been resolved, and targets the “Reflective” and “Integrative” phases; and

Step 3 – Traditional Therapy, which occurs during the “Reintegration” phase of grief

John R. Jordan, PhD, is a clinical psychologist and grief counselor who has specialized in working with survivors of suicide loss for many years in the Boston metropolitan area. He also regularly provides training for mental health professionals, clergy, and others throughout the United States, Canada, and Australia on working with individuals and families after suicide. He is a consultant for the Survivor Council of the American Foundation for Suicide Prevention and the Grief Support Services of the Samaritans of Boston. Dr. Jordan has authored numerous important publications in the bereavement field and was the recipient of the Association for Death Education and Counseling Research Recognition Award in 2006. He is also coauthor of two books in the suicide bereavement field: “After Suicide Loss: Coping with Your Grief “and “Grief after Suicide: Understanding the Consequences and Caring for the Survivors”. With the sponsorship of the American Foundation for Suicide Prevention, he also authored the Foundation’s Support Group Facilitator training program and manual for survivors and professionals who would like to facilitate self-help support groups. therapy.

The therapeutic modalities he recommends include Trauma Reduction Techniques, Cognitive Behavioral Therapy, Narrative Therapy, Psychodynamic Therapy, Family Therapy, Complicated Grief Therapy and traditional Grief Therapy. Peer and/or facilitated support groups can also play a central role in recovery.

As noted, the job of the complicated grief counselor shifts according to the stage of therapy, and includes the following multiple, overlapping and reoccurring roles:

1. We bear witness to the client’s exploration and expression of emotion, beliefs and experience of loss.
2. We are the psycho-educational coach; teaching the client about normal human responses to loss.
3. We are the life skills coach; helping the client identify what supports they need and how to ask for help from others.  This includes teaching progressive desensitization skills to reduce avoidance of loss, or containment skills to prevent flooding and overwhelm of loss thoughts, feelings or memories.
4. We are the client’s confidante
5. We serve as a transitional attachment figure
6. We are the psychotherapist; linking loss to other life issues, for example, earlier childhood loss, trauma or injuries leading to negative beliefs, expectations, feelings or moods. The therapist can also help the client overcome narcissistic perspectives, such as “I hurt more than you,” that can drive others away. In this way, therapy becomes an opportunity to revisit, rework and heal old wounds.
7. And we can serve as the client’s spiritual companion, helping the client use their grief for personal growth and transformation.

Therapeutic Strategies

Psychotherapy of chronic grief draws from a variety of counseling approaches, depending on the stage of therapy, presence of trauma, nature of the loss and client personality factors.  A main challenge is assisting the client to overcome avoiding or becoming overwhelmed by the loss. Both avoidance and flooding defenses need to be minimized for healthy grieving to occur.

Complicating factors for successful chronic grief therapy include active substance abuse and/or pre-existing mental health problems. In my experience as a certified addiction counselor, any addictive behavior – which in effect masks, represses, distorts or numbs healthy emotional expression and working through affective distress – must stop for therapy to be effective. Specific treatment strategies for mental health concerns (e.g. depression, bi-polar disorder) may need to be incorporated into the overall treatment plan.

Methodology

John Jordan (2011) writes that core treatment tactics for recovery from chronic grief may include:

1. Trauma Reduction Techniques:  a. Cognitive Therapy: Evaluates negative beliefs associated with trauma, e.g. “I’m a bad person.”b. Relaxation Techniques: Teaches diaphragm breathing and uses guided imagery or hypnosis to reduce nervous system arousal.
2. Dosing Techniques: Designed to assist the client to achieve more control over when and how much to experience their grief. By learning to choose when to ‘dose’ themselves or to pull back from grief, clients come to accept the reality of their loss while overcoming trauma symptoms, negative beliefs and distressing emotions. This skill acquisition makes the grieving process more conscious and voluntary, and builds psychological resilience.
3. Prolonged Exposure Therapy: Combines relaxation techniques with gradual exposure to traumatic stimuli, which is described in detail, recorded, and listened to at home;
4. Meaning Reconstruction: Uses journaling to write about the traumatic event in detail, repeating the writing four to six times over a two week period;
5. Writing Letters: To or from deceased and/or an empathic ‘imagined’ friend who knows what the client needs to heal;
6. Restorative Retelling: Recalling the traumatic loss scene and then retelling the incident in a more bearable way that does not preclude the loss;
7. Alternate Ending: Uses guided imagery to portray the worst case scenario, real or imagined, which is then transformed to the best case scenario, then reviewed;
8. Activism: Involvement in support groups and helping others in a way that is redemptive or meaning-making.  For example, Compassionate Friends support groups for bereaved parents;
9. Relational Repair: Occurs at the end stage of therapy. Designed to mend ruptures in relationships, it can also be an opportunity to conclude unfinished business e.g. ‘complete’ a relationship with a person who died by suicide.
10. Complicated Grief Therapy:  A 16 session program developed by Dr. Kathryn Shear, MD to treat prolonged bereavement. Using the dosing technique of having the client retell the story of the death several times, the therapist points out shifts in the narrative, clarifying signs of strength and working through negative beliefs.
11. Rituals: New rituals or traditions of commemorating loss are built alongside old rituals to help the client move into their new post-loss identity, while continuing to process their grief in a healthy manner.

Complicated Grief Assessment Strategies

When conducting the initial evaluation of a client who presents with symptoms of complicated grief it’s important to conduct a detailed assessment as this will guide the timing and specifics of treatment interventions. Important assessment questions address how much:

1. The client is having trouble accepting the loss;
2. Grief is interfering in the client’s life;
3. The client is experiencing intrusive images or thoughts of the loss that really trouble them;
4. The client is avoiding things they used to do/enjoy before the loss;
5. The client is feeling cut off or distant from others; especially family or friends;
6. The client is having intense feelings of loneliness when in the company of people they are close to;
7. The client is either avoiding thinking about the loss, or is overwhelmed by memories, images, thoughts or emotions;
8. Trauma symptoms may be interfering in the client’s daily life and grief recovery.

It’s also important to assess for the client’s ability to see reality as it is, their coping style (a balance between avoidant and confrontational is healthiest), a history of loss, trauma or mental health concerns, what the loss means to the client, the presence of additional stressors, quality of social support, and the griever’s expectations for therapy and recovery.

Preliminary studies of the efficacy of Complicated Grief Therapy are extremely hopeful as they show that the recovery rate is twice that of regular grief counseling (Shear, 2010).  These findings suggest that proficiency in chronic grief therapy methods is an essential skillset that therapists must acquire in order to help their clients regain their psychological well being.

References

Jordan, J. (2011). Traumatic Loss: New Understandings, New Directions. CMI Education  Institute. Eau Claire, WI.

Worden, W. (2009). Grief Counseling and Grief Therapy, 4^th Edition, Springer  Publishing, New York, NY.

Shear K, Frank E, Houck PR, Reynolds CF. (2005).  Treatment of Complicated Grief: A Randomized Controlled Trial. Journal of the American Medical Association. 293(21): 2601-2608.

[1] This is a ‘rule of thumb’ amongst mental health clinicians.  The Diagnostic and Statistical Manual of Mental Disorders (DSM V) published by the American Psychiatric Association in 2013 has included Persistent Complex Bereavement Disorder (PCBD) in the Emerging Measures and Models section, with a view toward including it in later revisions of the DSM.

Photo – BC Association of Clinical Counselors

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Glynis Sherwood – MEd, Canadian Certified Counselor, Registered Clinical Counselor, specializes in helping people recover from all kinds of Loss, Grief and Stuck Grief – aka ‘the pain that won’t go away.  I look forward to hearing from you and helping you achieve the peace of mind you want and deserve.

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