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Grief Therapy

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Grief Therapy

Oxford Research Encyclopedia of Psychology

Grief Therapy  
Robert A. Neimeyer and Melissa A. Smigelsky
Subject: Clinical Psychology: Disorders and Therapies Online Publication Date: Feb 2018
DOI: 10.1093/acrefore/9780190236557.013.73

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.

Keywords: grief therapy, bereavement, death, complicated grief, loss

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Grief Therapy

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.

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Grief Therapy

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

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Grief Therapy

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

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Grief Therapy

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).

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Grief Therapy

Bereavement Trajectories
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

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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

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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).

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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
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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.

Converging Perspectives
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.

Further Reading

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Kosminsky, P., & Jordan, J. R. (2016). Attachment-informed grief therapy. New York:
Routledge.

Neimeyer, R. A. (Ed.). (2012). Techniques of grief therapy: Creative practices for

counseling the bereaved. New York: Routledge.

Neimeyer, R. A. (Ed.). (2016). Techniques of grief therapy: Assessment and intervention.

New York: Routledge.

References
Boelen, P. A., de Keijser, J., van den Hout, M. A., & van den Bout, J. (2007). Treatment of
complicated grief: A comparison between cognitive-behavioral therapy and
supportive counseling. Journal of Consulting and Clinical Psychology, 75(2), 277–284.

Bonanno, G. A., Wortman, C. B., Lehman, D. R., Tweed, R. G., Haring, M., Sonnega, J., . . .
Nesse, R. M. (2002). Resilience to loss and chronic grief: A prospective study from
preloss to 18-months postloss. Journal of Personality and Social Psychology, 83(5),
1150–1164.

Bonanno, G. A., Wortman, C. B., & Nesse, R. M. (2004). Prospective patterns of

resilience and maladjustment during widowhood. Psychology and Aging, 19(2), 260–
271.

Bowlby, J. (1980). Attachment and loss: Loss, sadness and depression (Vol. 3). New York:
Basic.

Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Maccullum, F., Cahill, C., . . .
Nickerson, A. (2014). Treating prolonged grief disorder: A randomized clinical trial.
JAMA Psychiatry, 71(12), 1332–1339.

Burke, L. A., Clark, K. A., Ali, K. S., Gibson, B. W., Smigelsky, M. A., & Neimeyer, R. A.
(2015). Risk factors for anticipatory grief in family members of terminally ill
veterans receiving palliative care services. Journal of Social Work in End-of- Life &
Palliative Care, 11(3–4), 244–266.

Burke, L. A., & Neimeyer, R. A. (2013). Prospective risk factors for complicated grief: A
review of the empirical literature. In M. Stroebe, H. Schut, P. Boelen, & J. Van den Bout
(Eds.), Complicated grief: Scientific foundations for health care professionals (pp. 145–
161). Washington, DC: American Psychological Association.

Coleman, R. A., & Neimeyer, R. A. (2010). Measuring meaning: Searching for and
making sense of spousal loss in late-life. Death Studies, 34(9), 804–834.

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complicated grief. Journal of Clinical Psychiatry, 67(2), 233–239.

Robert A. Neimeyer

Professor, Clinical Psychology, University of Memphis

Melissa A. Smigelsky

Clinical Psychology, University of Memphis

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