M. Katherine Shear M.D.

Professor of Psychiatry, Columbia University

www.complicatedgrief.columbia.edu

PART I: Complicated grief

Grief and adaptation to loss: acute, integrated and

complicated grief (CG; persistent impairing grief)

How to diagnose CG: using ICD11 PGD

PART II: Complicated grief therapy (CGT)

The evidence base

CGT as adaptive grief therapy: target, themes and

procedures

Defining grief

Grief is the response to loss and the form love

takes when someone dies

it’s permanent when someone we love dies

A range of emotions,

thoughts, behaviors and physical changes

Spiritual and Social changes

Still…there are important

commonalities

and variable

Acute Grief: the initial Response to Loss

Insistent Thoughts of the deceased person,

disbelief, difficulty concentrating

along with a renewed sense of purpose and meaning and

renewed connections to others

Integrated grief has a place in our lives…

To adapt to loss…1. We find a way to accept the reality of the death, including

a changed relationship to the person who died

2. And to envision a future with possibilities for happiness

Bereavement

Adapt to the lossAcute Grief

Accept the reality

Envision the future

Isn’t all grief complicated?

The answer depends on how you define the term.

In everyday life English “complicated” means something

with intricately combined parts or something that is

difficult to analyze, understand, or explain;

In this sense grief is often complicated

In medicine “complicated” refers to a process in which a

superimposed problem prolongs the healing process.

Less than 10% of grief is complicated.

“Complicated grief is complicated and cannot be

confined to one syndrome or disorder.

An illustrious group of colleaguesTherese Rando,

Kenneth Doka, Stephen Fleming, Maria Helena Fanco, Elizabeth

Lobb, Colin Murray Parkes, Rose Steele

A Call to The Field: Complicated Grief in the DSM-5

Omega, Vol. 65(4) 251-255, 2012

But there is another definition of complicated

grief…

From Rando et. al.:

“…not just a single form of complicated grief, but

rather many forms of it. ..we urge … that future

endeavors seek to identify other forms of

complicated grief…

[We favor] the delineation of additional diagnostic

categories with their distinct criteria.”

This would produce a catalogue of bereavement-

related psychiatric diagnoses.

Is this really what we need?

ICD11 and DSM5 have weighed in

Both workgroups entertained proposals for a new diagnosis

and both concluded that there was substantial evidence to

support it

Both workgroups grappled with what to call this syndrome

and with two different empirically derived proposals for

criteria – one of them ours

Both workgroups rejected the label “complicated grief”

ICD named the condition Prolonged Grief Disorder, and

developed a simple, clinically meaningful guideline

DSM named the condition Persistent Complex

Bereavement Disorder and developed a complex lengthy

algorithm

There is recognition of a syndrome of persistent

impairing grief, but there are at least 3 different

names: CG, PGD, PCBD and four proposed criteria PGD : ICD PGD, PLOS PGD, and DSM5 PCBD

Do these terms refer to the

same or different

individuals?

How are they related to each

other?

ICD and DSM: current status

The guideline for PGD is included in the recently released ICD11

draft, slated for approval in 2019

DSM placed PCBD in Section 3, issuing a call for more research

on the criteria

We have conducted tests of the different criteria sets in two

independent samples

1) A clinical treatment-seeking sample, independent from the

one in which we developed the proposed criteria

2) A community-based survey of bereaved military family

members

PGD criteria have been used in many interesting studies since

2013; however, to our knowledge, the only tests of the criteria are

our own and a re-analysis of the original data

Stephen Cozza, M.D., F. Edward Hebert School of Medicine, Uniformed Services University

Barry D. Lebowitz, Ph.D., University of California, San Diego

Philip Lavori, Ph.D., Biomedical Data Science, Stanford University

Christine Mauro, Ph.D., Columbia University Mailman School of Public Health

Charles F. Reynolds III M.D., University of Pittsburgh Medical Center and Graduate School

of Public Health

Naomi M. Simon, M.D., M.Sc., New York University School of Medicine

Robert J Ursano M.D., F. Edward Hebert School of Medicine, Uniformed Services University

Sidney Zisook, M.D., University of California, San Diego

Performance of DSM-5 Persistent

Complex Bereavement Disorder

Criteria in a Community Sample of

Bereaved Military Family Members

Cozza et al 2016

“Participants were surviving parents, spouses/partners,

siblings, and adult children (N=1,732) of service members in

the U.S. military (Army, Navy, Air Force, Marines, and Coast

Guard) who died by all circumstances of death (i.e., combat,

accident, suicide,homicide/ terrorism, illness, undetermined)

since September 11, 2001.”

Under the advice of two independent senior biostatisticians, the study

evaluated the conditional probability of diagnosis in two groups: those

who almost certainly did have persistent impairing grief and those who

almost certainly did not.

Clinical cases who almost certainly have the condition: ICG

score at least 30 and Work and Social Adjustment Scale score

at least 20

N= 260; 15% of the overall sample

Nonclinical cases who almost certainly do not have the

condition: ICG score <20

n=675; 39% of the overall sample

PCBD: 53% of clinical cases diagnosed; 100% of non-clinical

cases excluded

PGD (Plos): 59% of clinical cases diagnosed; 100% of non-

clinical cases excluded

CG: 92% of clinical cases diagnosed; 98% of non-clinical cases

excluded

Cozza et al 2016

Using the same criteria for clinical caseness (ICG > 30 and

WSAS > 20)

PGDPLOS and PCBD criteria correctly identified about 50%

of cases and accurately excluded 96%

CG and ICD11PGD criteria correctly identified about 80%

and accurately excluded more than 85%

Diagram by Stephen Cozza M.D.

CG and ICD11 PGD identify the same people

PCBD and PLOS PGD identify the same people

PLOS PGD DSM5 PCBD

Mean Score Mean Score

Inventory of Complicated Grief 41 40

Work and Social Adjustment Scale 22 21

Performance characteristics and

clinical utility of diagnostic criteria

proposals in bereaved treatment-

seeking patients

Mauro et al 2017

Grief treatment-seeking participants bereaved for at

least 6 months (n = 240) were recruited from ongoing

studies at university based psychiatric research clinics at

Columbia University (n = 70), Massachusetts General

Hospital (n = 58), University of Pittsburgh Medical Center (n

= 55) or University of California San Diego (n = 57).

A comparison group of bereaved participants was

constituted from ongoing research studies at

The Latelife Depression Prevention and Treatment

Center (P30 MH90333) at the University of Pittsburgh

Medical Center (n = 62) or

The Center for Anxiety and Traumatic Stress Disorders at the

Massachusetts General Hospital (n = 24).

For these participants, a mood or anxiety disorder was the

primary diagnosis established using a structured clinical

interview for DSM-IV and all scored <20 on the ICG.

Nonclinical grief cases in treatment seeking sample

A score of 30 or higher on the original 19-item ICG (strong

evidence that an ICG score of 25 identifies clinically

significant symptoms)

Judged by an experienced clinician to have CG as the

condition most in need of treatment.

Affirmative response to the question: ‘Overall, is grief

interfering a lot with your ability to work or socialize or

function in other ways?

Criteria setCorrectly identify clinical

casesn=240

Correctly identify clinical non-cases

n=86

ICD11PGD 93% (90 – 97) 100%

CG 100% (99 – 100.0) 100%

DSM5 PCBD and PLOS PGD criteria fail to identify a substantial

proportion of these individuals

PCBD 70% (64 – 76) 100%

PGD PLOS 50% (53 – 66) 100%

Results from our field trial of DSM5 criteria in clinical

samples

Prolonged grief disorder: clinical utility

of ICD-11 diagnostic guidelines

Christine Mauro, Charles F. Reynolds III, Andreas Maercker,

Natalia Skritskaya, Naomi Simon, Sidney Zisook, Barry Lebowitz, Stephen J. Cozza, M. Katherine Shear

Study participants with persistent impairing grief (n = 261)

were enrolled at a university-based psychiatric research clinic

at Columbia University (n = 23), Massachusetts General

Hospital (n = 82), University of Pittsburgh Medical Center (n

= 72), or University of California San Diego (n = 84) as part of

the National Institute of Mental Health (NIMH)-funded

collaborative treatment study (MH60783; MH85288;

MH85308; MH85297).

Operationalizing

ICD11 Guideline

using the

Structured Clinical

Interview for CG

(SCI-CG)

Mauro et al 2018

Varying requirement for number of associated

symptoms for ICD11 diagnosis

Mapping the PGD PLOS criteria onto the Structured

Clinical Interview for CG (SCI-CG)

Mauro et al 2018

The operationalized ICD-11PGD guideline correctly

identified 250/26: 96% (CI 93.3–98.2%)

PGDPLOS criteria correctly identified 154/261: 59%

CI 53.0–65.0%) χ2 = 96.0, df = 1, p < 0.0001

Neither of the PGD criteria incorrectly diagnosed a

bereaved clinical sample without evidence of persistent

grief.

Mauro et al 2018

Marital status : Widows more likely to receive a diagnosis

(74%), than other participants, especially those who were

married (38%) χ2 = 18.3, df = 3, p = 0.0004

Co-occurring MDD Those with a concurrent diagnosis of

depression more likely to receive a diagnosis (64%) than

those without depression (45%) χ2 = 7.8, df = 1, p = 0.0051

Mauro et al 2018

Person lost Those bereaved of a partner (69%)more likely to

receive a diagnosis than other participants, especially those who

lost a child (50%) or other (45%) χ2 = 9.23, df = 3, p = 0.0264

Circumstances of death Those bereaved by a non-violent death

(65%) more likely to receive a diagnosis that those bereaved

violently (47%) χ2 = 7.6, df = 1, p = 0.0058

Mauro et al 2018

NO DIFFERENCES in treatment response among those

diagnosed or not using PGDPLOS criteria

Response to CGT: 85.2% v. 87.7%

χ2 = 0.04, df = 1, p = 0.8345

Treatment adherence: 70.6% v. 74.4%

χ2 = 0.22, df = 1, p = 0.6377

Response to meds/clinical management: 57.5% v. 64.7%

χ2 = 0.49, df = 1, p = 0.4831

Mauro et al 2018

Persistent and pervasive longing or preoccupation with the deceased causing

significant impairment in important areas of functioning

At least one additional indicator of intense emotional pain, such as sadness,

guilt, anger, denial, blame, difficulty accepting the death, feeling one has lost

a part of one’s self, emotional numbness

Persists at least 6 months and clearly exceeds expected social, cultural or

religious norms for the individual’s culture and context.

ICD 11 Guideline For Prolonged Grief Disorder

Conclusion: The ICD11 Guideline is an excellent way of

identifying individuals who may benefit from treatment

Bereavement

Adapt to the lossAcute Grief

Accept the reality

Envision the future

DYSFUNCTIONAL BEHAVIORS

Excessive avoidance, social withdrawal, substance use;

negative health behaviors

PROBLEMS REGULATING FEELINGS Overly intense negative emotions, low positive emotions, low self-

compassion

MALADAPTIVE THOUGHTS Second-guessing; grief-judging, catastrophizing the future

SEVERE SOCIAL/ENVIRONMENTAL PROBLEMS

Lack of any supportive companion; blamed by others;

homeless, in poverty, loss of employment

Bereavement

AdaptationAcute Grief Integrated Grief

X XImpediments

Complicated Grief

(persistent impairing grief)

Estimated Population Prevalence:

7% Of Bereaved People

Rate Is Higher (About 15%) Among

Those Bereaved By Violent Death

Grief is the story of love after loss.

It’s not a state or a moment in time or a

single emotion.

A grief story usually unfolds and evolves as we

adapt to the loss.

…and grief finds a place in our lives

People experiencing complicated grief are relieved

to hear that we know who they are

OUR RADIO AD

Have you lost someone you love? Do you often feel like

you Are stuck in a place of pain and grief? Have others

begun to Grow weary of hearing you talk about your loved

one? Maybe You miss the person so much that it’s hard to

care about anything else.

You might be suffering from complicated grief. If you are,

the pain of the loss stays fresh and healing does not occur,

it seems like time is moving on but you are not.

Screening questionnaires

Brief grief questionnaire (BGQ: 5-items) developed for Project

Liberty survey and performed well

Inventory of complicated grief (ICG: 19 items) first instrument to

identify CG – a highly reliable screening tool

Structured Diagnostic Interview

Structured Clinical Interview for CG (SCI-CG: reliable and valid)

...or do a Clinical interview

Elicit symptoms of acute grief and grief complications

Bereavement

adaptationAcute Grief

Integrated

Griefx x

impediments

Grief Therapy

Identify and resolve

impediments

Facilitate adaptation

71%

44%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% Average Response Rates across 3

NIMH-funded randomized

controlled trials (n=643)

CGT

CONTROL

Study 1: P=0.006 NNT, 4.6

Study 2: P < .001; NNT, 2.56

Study 3: P = .002;NNT, 3.6

WEEK 20

CITALOPRAM

PLACEBO

CGT + CITALOPRAM

CGT + PLACEBO

Week 0

CGT = Complicated Grief Therapy

WEEK 12

Also, an AFSP pilot study of 58Suicide bereaved individuals

Added to the NIMH study

Preliminary data regarding feasibility, acceptability and effectiveness of CGT among survivors of suicide with CG

All participants received CG-informed

clinical management

Naomi Simon MD

PI: MGH

Sid Zisook MD

PI: San Diego

Chip Reynolds

MD

PI: Pittsburgh

Kathy Shear MD and Naihua Duan PhD

PI’s Coordinating Site:

Columbia University

Meet the HEAL PI’s

HEAL confirmed efficacy of CGT

CGT markedly reduced symptoms of CG and SI in severely ill and highly comorbid individuals

Antidepressant medications did not improve CG outcome but did produce a significantly greater reduction in depression

Antidepressant medication was not significantly different from placebo for CG symptoms

58

Age M (SD) 53.0 (14.5)

Gender N (%)

Female 308 (78%)

Race N (%)

White 325 (82%)

Black 39 (10%)

Others 31 (8%)

Hispanic N (%) 45 (11%)

Person who died N(%)

Partner 144(36%)

Parent 113(29%)

Child 80(20%)

Other relative or friend 58(15%)

Time since loss M(SD), years 4.7(7.2)

Violent death N(%) 132(33%)

→ Suicide Bereaved 58(15%)

60

MDD current N(%) 262(66.3)

PTSD current N(%) 154(39.0)

CGI severity rating N(%)

Mildly/Moderately ill 130(32.9)MARKEDLY ILL 199(50.4)SEVERELY/extremely ill 66(16.7)

Since death wish to be dead N(%) 221(55.9)Since death non-specific active

suicidal thoughts N(%) 103(26.1)

Shear et al JAMA Psych 2016

Responder defined as much or very much improved

Using a global improvement scale

1) Very Much Improved – Compared to baseline: clear

evidence that grief intensity and impairment is

markedly improved. The person feels very differently

about the role grief plays in their life.

2) Much Improved –Compared to baseline, grief intensity

and impairment are definitely and meaningfully

improved. The person notices a definite difference in

the role of grief in their life.

4. Moderate– CG intrusive, painful but bearable

Some interference with functioning, not substantially impaired;

avoidance of reminders may occur; sense of purpose maintained but

weakened; suicidal thoughts may occur but desire to live; distraction

possible temporarily

4. Marked –CG frequent and intrusive with substantial pain

Definite interference with functioning; some avoidance of reminders;

loss of sense of purpose, uncertain if happiness is possible; suicidal

thoughts usually present; distraction difficult and short-lived

5. Severe –CG nearly constant and preoccupying;

Severe and impairing; extensive avoidance of reminders; feeling

happiness satisfaction is no longer possible; active suicidal ideation

or indirect suicidal behavior; distraction rarely possible and only

partially effective

0 1 2 3 4 5 6 7 8 None Mild Moderate Marked Severe

interference interference interference interference

Because of grief my ability to do the following is

impaired…

1. Work

2. Home management

3. Private leisure activities

4. Social leisure activities

5. Ability to form and maintain close

relationships

0 1 2 3 4

Not at all Somewhat Moderately Strongly Very

strongly

This death should not have happened

You should have done something to prevent the death or make it easier

Someone else could have prevented this death or made it easier

The world is filled with unpredictable dangers

Illness-related deathn=263

Violent deathN=132

Moderate 31% 36%

Marked 53% 45%

Severe 16% 18%

0

10

20

30

40

50

60

70

SI (Before Death) SI (Since Death)

52

66

30

54

Suicide Bereaved

Not Suicide Bereaved

*

*

P<0.05

Controlling for age, time since death, relationship and gender

Suicide Bereavement and Suicide Ideation

68

46% 38%

0%

20%

40%

60%

80%

100%

Week 12

CIT PLA

83% 84%

0%

20%

40%

60%

80%

100%

Week 20

CGT + PLA CGT + CIT

Shear et al JAMA Psych 2016

70

CGT + PLA vs. CGT + CIT

0%

10%

20%

30%

40%

CGT + PLA CGT + CIT

Pe

rc

en

t w

ith

Su

icid

al

Ide

ati

on

Week 1 Week 20

4%

0%

10%

20%

30%

40%

PLA CIT

Pe

rc

en

t w

ith

Su

icid

al

Ide

ati

on

Week 1 Week 20

32% 31%

21% 21%

PLA vs. CIT

26%32%

7%

Shear et al JAMA Psych 2016

Boston, New York, Pittsburgh, San Diego

Shear et al JAMA Psych 2014

73

52

9

69

7

54

70

10

20

30

40

50

60

70

80

Wish to die before treatment Wish to die after CGT

Suicide Homicide Natural death

Zisook et al J Clin Psych, 2018

74

41

0

31

0

19

40

5

10

15

20

25

30

35

40

45

Active SI before treatment Active SI after CGT

Suicide

Homicide

Natural death

Zisook et al J Clin Psych, 2018

Persistent impairing grief is a recognizable syndrome that occurs when troubling concerns and excessive avoidance derail the healthy mourning process

ICD11 Guideline for Prolonged Grief Disorder is an excellent way to diagnose these individuals

This condition is associated with high rates of suicidal ideation

Individuals who meet any of the criteria respond well to our targeted adaptive treatment

75

Integrated

Grief

Bereavement

XX

Adapt to the loss

Acute Grief

Impediments

Therapy goalsFind and resolve

impediments

Facilitate adaptationEncourage personal growthBuild resilience

Complicated Grief Therapy

A short-term evidence-based adaptive intervention

ObjectiveTo facilitate the natural

adaptive process

Complicated Grief Therapy: A short-term intervention

However, grief is not the problem and is not a

target for intervention

What is our relationship to suffering?

“Almost eight months after the Japanese tsunami, I accompanied the Dalai

Lama to a fishing village, Ishinomaki, that had been laid waste by the natural

disaster. Gravestones lay tilted at crazy angles when they had not collapsed

altogether. What once, a year before, had been a thriving network of schools

and homes was now just rubble. Three orphans barely out of kindergarten

stood in their blue school uniforms to greet him, outside of a temple that had

miraculously survived the catastrophe. Inside the wooden building, by its

altar, were dozens of colored boxes containing th remains of those who had

no surviving relatives to claim them, all lined up perfectly in a row, behind

framed photographs, of young and old.

As the Dalai Lama got out of his car, he saw hundreds of citizens who had

gathered on the street, behind ropes, to greet him. He went over and asked

themhow they were doing. Many collapsed into sobs. “Please change your

hearts, be brave,” he said, while holding some and blessing others. “Please

help everyone else and work hard; that is the best offering you can make to

the dead.” When he turned round, however, I saw him brush away a tear

himself.”

Pico Iyer The Value of Suffering - The New York Times http://www.nytimes.com

Warming things up

Turning on a light

CGT focuses on...

and opening a door to the outside world

What adapting

means .

“A dynamic, ongoing, life-sustaining process by

which living organisms adjust to environmental

changes”

https://medical-dictionary.thefreedictionary.com/Physiological+Adaptation

We are naturally predisposed to adapt to loss

How we adapt to loss

Accept the reality of the death - its finality and consequences and

changed relationship with the person who died

Envision a future with a sense of purpose and meaning and

possibilities for happiness

1. Loss- focused

Understanding the personal meaning of the loss; Coping with everyday life

stresses that the death brings; Navigating a world of absence;

Accepting the permanent absence of the person who died; Managing grief

and difficult times

Connecting in a meaningful way to memories of the person who died

Accepting the change – the painful reality of the death

1. Restoration-focused

Reconnecting with personal intrinsic motivation – core values and interests

Restoring a sense of competence, interest and enjoyment in everyday life;

re-establishing strong relationships; accepting grief and managing

emotional pain

Using personal assets and resources to promote health and wellbeing;

enjoying strong relationships; allowing grief a place while envisioning a

promising future with possibilities for joy and satisfaction

Seeing possibilities for a promising future

Grief changes as a person adapts to the loss

There is a renewed

sense of purpose and

meaning and renewed

connections to others

However grief is integrated

and no longer dominates the

person’s life

However, grief intensity can still surge in response to life events or calendar

days that are reminders of the loss

Understanding grief

Managing painful

emotions

Thinking about the future

StrenghtheningSocial

Relationships

Telling thestory of the

death

Living withreminders

Connecting to memories

We can deepen our understanding of grief by understanding close relationships

84 different definitions or

characteristics

Everyone loves in their own way

Fehr B and Russell J:

The Concept of Love

✓ Biologically motivated

✓ Mediated by internalized mental representations

✓ A source of wide ranging effects on our lives

Feels rewarding

Provides comfort and solace

Encourages personal growth

and discovery

Defining features of secure attachment

The urge to seek, form and maintain secure relationships is rooted in our biology

The interpersonal self may be more important to

self concept than the inner-directed self

Close attachments are cornerstones in our

construction of self

Relational self-construal

Self-compassion

Self affirmation and authenticity

Sense of self-expansion

Self concept complexity

Self concept clarity

The stronger, more satisfying the relationship

the greater its importance to our self concept

and the greater our…

PSYCHOLOGICAL

Emotions, Thoughts, Attention, Social Behavior

SENSE OF SELF

Identity, Coherence,, Values and Goals

PHYSIOLOGICAL

Sleep Quality, Pain Intensity, Temperature Regulation

Hormonal Response to Stress, and More

The attachment motivational system is linked to

systems for exploration and caregiving

Secure attachment comes

in many shapes and sizes

We are deeply motivated to serve as a safe haven

and secure base

Secure attachment and effective caregiving usually

go hand-in-hand

For most of us, being an effective caregiver is at least as

important as receiving effective care

Motivation to explore the world

Desire to learn, grow, discover, accomplish goals

Attachment system activated

Caregiving system activated

Exploratory system inhibited

The net result is a disorienting and disruptive

experience

Acute attachment insecurity:

Anxiety, guilt, sadness, anger

Proximity seeking

Acute caregiver ineffectiveness:

Separation guilt

Proximity seeking

Loss of interest in learning and

discovery

Loss of sense of competence

“Proximity seeking” activated

Yearning, longing, frequent insistent thoughts and memories; wide-ranging psychobiological dysregulation

Loss of sense of safety

Feelings of sadness, anxiety, anger, insecurity, mistrustfulness, guilt

Sense of caregiver ineffectiveness

Feelings of not caring about others, self-blame, anger, remorse

Exploration inhibited

Difficult to care about anything other than the deceased; loss of motivation to learn, discover new things or perform in the world

Yearning, longing,

preoccupation, guilt

Loss of interest in

exploring the world,

learning and growing

Dysregulation in body

and mind: dysphoria

Activated attachment and caregiving systems

Inhibited exploratory system

Loss of psychological and physiological regulation Over all, a highly

emotional,

disorienting and

disruptive experience

Theme 2: Managing painful emotions

We work with both painful and pleasant emotions

Ways bereaved people can manage painful

emotions

Oscillating attention

Self-compassion

Self observation, reflection

Meaningful social companionship

Grief monitoring

Understanding grief

Promoting emotion regulation

Observing and reflecting on an emotional experience is a way of

diminishing its intensity.

In addition the recording pattern can help people understand the ebb

and flow of grief intensity and pay attention to emotions they are

feeling.

Oscillate from pain to respite

Self-observation and reflection

xxxx

Self-compassion

Exploit possibilities for agency

Experience positive emotions

Receive support from others

Notice variations in grief intensity

Observe situations associated with high

and low grief intensity

Reflect on grief levels

Notice effects of being active

Reflect on low grief levels

Share observations of grief levels

However, monitoring grief levels can seem counterintuitive

to grieving people

Explore long-term life aspirations or dreams -

activities or goals - that can bring personal

satisfaction and are consistent with intrinsic

interests and/or values

Based upon social psychologists Deci and

Ryan Self-determination theory with

extensive research backing

We uses a procedure that is a modification of a

motivational interviewing procedure called “personal

goals” work

Planning simple

everyday rewarding

activities

Two procedures that

track through the treatment

Creating and working

toward long-term

aspirational goals

Feeling of belonging and mattering is a basic human need

Bereavement robs us of a sense of belonging

A premise of CGT:

The presence and support of loving companions is an

important context for successful adaptation to loss

1. Discuss the relationship between the visitor and the client

2. Get the visitor’s perspective on the person who died and the

client’s life since the death

3. Provide an overview of grief, adaptation to loss and adaptive grief

therapy

4. Discuss how friends and family can support a grieving person in

adapting to the loss

“Listening is a magnetic and strange thing, a creative

force… When we are listened to, it creates us, makes us

unfold and expand.”

From Lipman: Brenda Uehland, “Tell Me More: On The Fine Art of Listening.”

In Strength to My Sword Arm. Holy Cow Press: Minneapolis, MN, 1996

(1941).

Theme 5: Telling the story of the death

To help understand what happened

Decide if it is final or can changed

Consider what it means for the future

To be free to keep thinking about it and keep

telling the story

There is never just one story

An opportunity to notice and work with

impediments to adaptation

To share the pain of loss

To practice managing painful emotions

To help understand and accept what

happened

To share the pain of the story

To notice and work with impediments to

adaptation

To see ways to manage painful emotions

The story of the death activates painful

emotions

5 Intervention procedures that target emotion regulation

1. Story telling is highly structured – almost like a therapeutic ritual

2. We check in with clients at regular intervals while they are telling

the story

3. We ask what it was like to tell the story

4. We pay attention to helping the client set the story aside

5. We spend time planning a rewarding activity and getting a

commitment to do it

Living with reminders is an important part of

adapting to loss

After a loved one dies, it is typical for

everyday events, places, people and things to

trigger painful reminders of the loss.

People sometimes think the best way to

manage the pain is to try to avoid these

triggers.

Avoidance has a place in the grieving

process; however excessive avoidance can

interfere with adapting to the loss

Trying to avoid leads to extensive restriction of

movement in the world and ends up backfiring.

Since reminders are ubiquitous,

bereaved people can’t really avoid

the pain of reminders of their

deceased loved ones

Reminders provide an opportunity to

learn about what the the loss means to

the bereaved person’s life

Learning to deal with the emotional

activation frees the bereaved person to

move about in the world as they wish

We consider facing these situations to be a natural

part of the process of adapting to a loss

Memories are residues of our

close relationships

Memories are living parts of us,

not photographs fixed in time;

they change and grow as we

change and as we learn new

things

“… how well they manage to take even death in their stride because although

death can put an end to them right enough, it can never put an end to our

relationship with them. Wherever or however else they may have come to

life since, it is beyond a doubt that they still live in us. Memory is more than

a looking back to a time that is no longer; it is looking out into another kind

of time altogether where everything that ever was continues not just to be,

but to grow and to change with the life that is in it still. The people we

loved. The people who loved us. The people who, for good or ill, taught us

things. Dead and gone though they may be, as we come to understand

them in new ways, it is as though they come to understand us—and

through them we come to understand ourselves—in new ways too. “ p.21

Bereaved people have a large reservoir of memories of the

person who died, both explicit and implicit.

However, with when grief is intense these memories may

seem too painful and trigger experiential avoidance

Or, memories may be compartmentalized and kept

separate from the loss

People with intense grief sometimes daydream about being

with their loved one.

This type of memory blocks out current reality – a kind of

dissociative state

The reality of the loss can’t color or shade the memories so

they don’t grow and change with the bereaved person

Summary

Persistent impairing grief affects millions of people worldwide

each year

This syndrome can be identified using ICD11 guidelines

CGT is a short-term evidence based adaptive therapy that can

help bereaved survivors adapt to the loss; it’s been proven

efficacious in 3 separate NIMH-funded studies carried out in 5

separate clinical laboratories.

CGT centers on 7 main themes and core procedures aimed at

helping people understand the finality and consequences of a

loss, change their relationship with the deceased and envision

their future in a way that has possibilities for joy and satisfaction

For professionals

Information and resources on our website

Training video series

Treatment Manuals

Assessment Instruments

Workshop series

Weekly peer support meetings on zoom

Webinars

For the public

Information and resources on our website

Handouts on grief and adaptation to loss and Difficult Times

Find a therapist

Information about research

For information visit our website

www.complicatedgrief.columbia.edu