Ulrich Schnyder and Marylène Cloitre (eds.)Evidence Based Treatments for Trauma-Related Psychological Disorders10.1007/978-3-319-07109-1_15

15. Complicated Grief Treatment (CGT) for Prolonged Grief Disorder

M. Katherine Shear¹

(1)

Columbia University School of Social Work, Columbia University College of Physicians and Surgeons, 1255 Amsterdam Avenue, New York, NY 10027, USA

M. Katherine Shear

Email: ks2394@columbia.edu

Sixty million people in the world die every year, leaving loved ones struggling to adjust. We expect to react strongly to the death of a loved one, but loss of a close relationship often creates havoc beyond what we expect. Close relationships anchor us, enrich our lives, and provide some of our greatest joys and deepest satisfactions. Dysregulated emotions and disruption of functioning occur when they die and the feelings are unfamiliar and disconcerting. People often wonder how they can ever accommodate to the new reality. Interestingly most people make this adjustment, often more quickly than they predict (Boerner et al. 2005; Wilson 2002). Grief is permanent after we lose someone very close, but symptoms usually decrease in frequency and intensity over time and we find ways to reenvision our own lives. However, people suffering from complicated grief (CG) (Shear et al. 2011) get lost in acute grief, unable to come to terms with the loss and unable to imagine purpose, meaning, or joy in life without their loved one.

The purpose of this chapter is to describe an efficacy-tested complicated grief treatment (CGT) for the syndrome in which acute grief is complicated and prolonged (Shear et al. 2005). Although there is not yet consensus on its name or on which criteria should be used to diagnose this grief-related syndrome, there is extensive data, reviewed in Chap. 6 of this book, to support its existence. Both DSM-5 and ICD-11 have proposed preliminary criteria. In the meantime, the 19-item Inventory of Complicated Grief (ICG) (Prigerson et al. 1995) is a simple screening tool with excellent psychometric properties that can be used to identify people suffering in this way. Participants in two clinical trials who scored over 30 on this scale and were judged to have CG as their primary problem showed a significantly better response to CGT than to grief-focused interpersonal psychotherapy (IPT).

15.1 Theoretical Underpinnings

In order to explain the theoretical underpinnings of CGT, we need to clarify the way our group uses terminology. Bereavement is defined as the situation of having lost someone close (Stroebe et al. 2003). As such, bereavement meets the definitions of trauma that entail confrontation with death, though not all bereavement is considered to be a trauma in the DSM-5. The impact of bereavement is related to the importance of the person who is lost as well as the circumstances and consequences of the death. In general, loss of a child or a romantic partner is the most challenging. Violent, unexpected death is also especially difficult (Kristensen et al. 2010).

Grief, defined as the response to bereavement, contains thoughts, feelings, behaviors, and physiological changes. The pattern, frequency, and intensity of these symptoms vary and evolve over time. Grief, like the love that spawns it, is unique to each person and each relationship. Still, certain features of grief are universal, including yearning and sadness, frequent thoughts and memories of the lost person, and feelings of disbelief and of alienation from ongoing life. The usual response to a loss includes an initial acute grief period that can be intensely painful and disruptive and that is gradually transformed to a permanent integrated grief that is much less insistent, no longer dominating the mind (Shear and Shair 2005). Most people are able to regulate emotions and to experience brief periods of positive emotions during acute grief (Moskowitz et al. 2003), and this facilitates the assimilation of information about the death and transformation of acute to integrated grief.

CGT utilizes attachment theory (Bowlby 1980; Mikulincer and Shaver 2003), self-determination theory (Ryan and Deci 2000), concepts of self-compassion (Neff and Vonk 2009) and neurobiological research on memory (Reber 2013; Hassin et al. 2009), reward system functioning (Burkett and Young 2012), and emotion regulation (Min et al. 2013). The approach utilizes strategies and procedures modified from prolonged exposure for PTSD (PE) (Foa et al. 2005), motivational interviewing (MI) (Miller and Rollnick 2013), and interpersonal therapy (IPT) (Weissman et al. 2000). The dual treatment objectives are to resolve grief complications and facilitate a successful mourning process.

Attachment theory was first proposed by John Bowlby in the mid-twentieth century. Since then research data have been obtained that strongly support the premises of this theory. Humans as well as other species are biologically motivated to seek, form, and maintain close relationships with a small number of other people. The closest of these bonds is usually between parent and child and between romantic partners in adults. Yet virtually any relationship can meet the characteristics of attachment relationships, namely, that proximity to the significant other is rewarding and separation resisted and that the attachment figure provides a safe haven and secure base. Attachment security contributes to psychological and physiological regulatory processes, and the disruption of a secure attachment relationship typically leads to profound emotional and physiological dysregulation.

The third of Bowlby’s famous trilogy provides a detailed discussion of the consequences of attachment loss. Bowlby defines mourning as “a fairly wide array of psychological processes set in train by the loss of a loved one irrespective of their outcome” (Bowlby 1980 p. 17) Successful mourning is the process by which a person adapts to loss. Typically, the mourner oscillates between confronting the painful reality and setting it aside such that information about the finality and consequences of the loss can be assimilated into the attachment working model. According to the CGT model, complicated grief is the condition that occurs when this assimilation is impeded by the presence of complicating thoughts, feelings, and behaviors.

Bowlby (1980) pointed to the importance of revising the internalized working model of the deceased person, essentially a form of working memory in which the mental representation of a loved one is used to devise goals and plans. Bowlby claimed that this revision is undertaken only slowly and with resistance. The usual process is one in which a bereaved person grapples with fully comprehending the finality and consequences of the loss by oscillating between attention to the reality and defensive exclusion. This oscillation produces bouts of intense emotional activation alternating with periods of respite. As a successful mourning process unfolds, the bereaved person comes to terms with the loss and regains a sense of relatedness, autonomy, and competence in his or her own life. The finality and consequences of the death are assimilated into long-term memory, a sense of self is restored, and the future holds the potential for happiness.

Self-determination theory provides another framework for understanding loss of a loved one. Bereavement is a life event that is usually ranked among the most stressful anyone can experience. One reason for this is that loss of a close attachment disrupts relatedness, autonomy, and competence, identified by Deci and Ryan (2000) as basic human needs. Our attachment relationships are an important source of our sense of relatedness defined as the sense of belonging and mattering to others. Attachment relationships provide a safe haven and secure base that facilitate autonomy and competence, and their loss can threaten these basic needs as well. From this perspective adjustment to loss is facilitated by reestablishing avenues for fulfilling basic needs.

Complicated grief is a form of prolonged acute grief in which this adaptive outcome does not occur. However, the problem is not grief itself which is seen as the manifestation of love after someone dies. Grief is permanent after a loved one dies, albeit usually transformed over time. However, with CG grief symptoms remain intense and interfere with the bereaved person’s capacity to restore his or her own life. Complications, using the term in the medical sense of superimposed problems, alter grief and interrupt its natural course.

Grief complications take the form of maladaptive thoughts, feelings, or behaviors that block the natural progression of grief. Maladaptive thoughts include rumination over some issue related to the circumstances, consequences, or context of the death. Inordinate difficulty with emotion regulation can be a grief complication. Maladaptive behaviors include dysfunctional avoidance of painful reminders of the loss and/or futile proximity seeking to try to escape the painful reality. CGT targets acceptance of grief as a manifestation of love, resolution of complications, and facilitation of successful mourning.

Self-compassion, meaning kindness toward oneself, feelings of common humanity, and mindful balance of accepting negative emotions without overidentification (Neff and Vonk 2009), is important in facilitating successful mourning. The occurrence of any unwanted and highly emotionally activating experience challenges feelings of self-compassion. Loss of self-compassion may be one of the predisposing factors in complicated grief. Encouraging self-compassion is a core principle employed throughout CGT.

15.2 How to Do CGT

CGT is a 16-session weekly treatment initiated after a pretreatment assessment establishes that CG is present and the patient’s most important problem. The treatment utilizes a set of key procedures that are employed in a structured sequence of four phases: getting started, core revisiting sequence, midcourse review, and closing sequence. Sessions begin by setting an agenda and reviewing the grief monitoring diary. Each session then addresses the goal of coming to terms with the loss followed by a focus on restoration of the potential for happiness in ongoing life. Sessions end with the therapist summarizing the session, obtaining feedback from the patient, and then discussing plans for the interval of time (usually one week) until the next scheduled session.

15.2.1 Pretreatment Assessment

CGT is designed to be used after completing an initial assessment in which complicated grief has been established as present and the most appropriate target for treatment. The existence of a condition in which acute grief symptoms are intense and prolonged is strongly supported in the literature. However, the current lack of consensus about how to identify such a syndrome can lead to some confusion. Our group opted to identify CG in a consistent manner until there are approved official criteria. Thus, all of our work, beginning in the late 1990s, has utilized the original 19-item ICG along with a semi-structured clinical interview. The 19-item ICG is a well-validated instrument that has been used throughout the world. Several other forms of this questionnaire exist, and this, again, can cause confusion, so we want to be clear about how we identify the individuals who have benefitted from CGT.

In CGT the therapist needs to have a basic understanding of the patient’s history, including important relationships and autonomous functioning. It’s a good idea to also complete a full psychiatric and medical evaluation to be sure that any associated problems are either addressed or monitored during the course of the treatment. Also, during the pretreatment assessment patients are provided with a general description of the treatment and its goals. They are given information that there are emotionally activating components to the treatment and that the success of the work will depend on their willingness to engage in these. The therapist also explains the importance of bringing the treatment into patients’ ongoing lives.

15.2.2 Sessions 1–3: Getting Started

The first phase of CGT focuses on history taking, providing psychoeducation, and beginning grief monitoring diary, aspirational goals, and building support. The therapist uses these sessions to establish a companionship alliance. The therapist conveys warmth, acceptance, and recognition that grief is a universal experience. At the same time, the expertise and willingness to serve as a guide for the patient’s grief journey are also apparent.

Introducing Marcy

Marcy is a 58-year-old woman who is neatly dressed. She sits in the waiting room filling out forms and crying. She enters the therapist’s office, struggles to gain control, and says she is sorry to be so emotional – this is not at all like her. She is a mess since her beloved husband Daniel died 5 years ago and, no offense intended, she doesn’t really see how anyone can help.

The therapist says there is no need to apologize for being emotional after a painful loss. Marcy seems to relax a little and thanks the therapist. Everyone else seems to think she is self-centered and pathetic, wallowing in her grief and not wanting to feel better. She wonders if this is true. She feels so lost like this is different from anything she ever dealt with and she doesn’t know what to do.

Marcy’s History

Marcy was the younger of two children, born in a tight-knit neighborhood close to where she currently lives. She describes her upbringing as difficult and lonely. Neither parent seemed very interested in her, and she often felt that she was just one more irritant in their sad lives. Her immigrant parents struggled to make ends meet, and her father was often irritable after long days at work. Her mother took in sewing and often seemed anxious and preoccupied during the day. In the evening, she focused on trying to pacify her husband, though she rarely succeeded. She remembers thinking that she was the one who caused her parents trouble and this made her scared and sad. She was close to her older brother, John, and they had a common group of friends. Marcy and John spent a lot of time together until he got to high school and started using drugs. After that they grew apart and were never close again. Now she is not sure where he is and has not talked to him since her father died more than 10 years ago. She met Daniel in college and always thought he reminded her of John. They got married a few years later. Marcy and Daniel were married for 35 years and had three children. They were unusually close. Their relationship was the envy of their friends.

Marcy’s CG Symptoms

Marcy has not moved any of Daniel’s things. His toothbrush is still in the bathroom. She can’t bear to have anyone sit at his desk. She cannot bring herself to sell his pickup truck, though she doesn’t know how to drive it. She avoids social occasions because she feels strangely incomplete when with other people and has painful feelings of sadness and shame. She avoids places where she is afraid she will miss Daniel too much – activities they enjoyed together, people they socialized with, and places where they spent time. Since his death, she has refused to go near the hospital where he died. She visits the cemetery infrequently because she can’t bear to think of him lying in the cold ground. Marcy wishes she would have died with Daniel.

Her only comfort is in reveries in which she imagines being with Daniel and thinks about how beautiful her life was when he was alive. When not day dreaming, Marcy often ruminates, feeling angry and bitter about Daniel’s death. She asks herself why they didn’t do the surgery before it was too late. She still can’t believe this nightmare really happened.

Marcy sometimes skips meals or forgets to take her cholesterol medicine, knowing this is not healthy. Even though she has lost her faith, her religious upbringing is all that keeps her from trying to take her own life. She and Daniel attended church regularly, but she lost faith in God after he died. What good is it to attend church if this is what you get? What kind of God would allow Daniel to die when people who are bad continue to live? She continues to work as an office manager for a medium-sized accounting firm but is having trouble concentrating. She no longer feels close to her children and describes herself as “just wandering around through life” thinking repeatedly, “why did he have to die? If only I had watched him more closely; if only I had convinced him to get to the doctor earlier; if only the doctors had treated him better….Why couldn’t the doctors help him?”

Grief monitoring is introduced in session 1. The patient is asked to keep a record of grief levels during the treatment, rating grief intensity on a 1–10 scale. At the end of each day, they record the highest level of grief that day and the situation in which it occurred, the lowest level and the situation in which that occurred, and the average grief level. The therapist also introduces the idea of building support and encourages the patient to invite someone to session 3. The purpose of the joint session is to both get another perspective on the patient’s situation and also to help a close friend or relative get some ideas about how they might help.

The restoration focus is introduced in session 2. The role of positive emotions is described along with self-compassion and self-determination needs for autonomy, competence, and relatedness. The therapist introduces the ideas of rewarding activities, aspirational goals, and rebuilding close relationships. The restoration-related component aims to help the patient access core values and interests and to use these in developing plans and goals. The patient also starts to build in simple activities that generate feelings of pleasure, interest, or satisfaction.

Marcy’s Aspirational Goal

Toward the end of the second session, the therapist asked, “If I could wave a magic wand and your grief was at a manageable level, what would you want for yourself?” Marcy stared at the therapist, surprised, and said that all she wants is to feel like she used to when Daniel was alive. The therapist accepted this, gently reminding Marcy that of course they couldn’t bring him back and that their job together was to help Marcy find some peace with this reality and a way to move forward in her life in a new way. If they succeeded in helping her somehow feel that she could deal with the painful reality, what would she want for herself? Marcy thought for a few minutes and then said, “OK I’ll try – I always wanted to play the viola. My mother made me play the violin when I was a child because her cousin gave her one. I never liked it and another girl at school had a viola and it sounded so much better to me.” Then she said that for some reason she had been thinking about this lately. She said Daniel always told her she should take viola lessons but she couldn’t ever find the time. He wanted her to play in a quartet. She said, “It’s so sad that I never did that when he was alive. I don’t know how I would feel trying to do something like that.” The therapist encouraged Marcy to keep thinking about the possibility of learning to play the viola.

Session 3 is usually held with a significant other. Its purpose is to reopen communication between the patient and a close friend or family member and foster support for the patient. Not infrequently, people with CG feel estranged from other people even though they have friends who want to help. However, eventually these friends start to feel helpless and become frustrated. The session gives the visitor the opportunity to express his or her affection for the patient, to air some of the frustration he/she has been feeling, and to share in supporting the treatment. The therapist learns about the visitor’s relationship with the patient before the death and what it has been like since. Patients may be surprised to see how much the visitor cares.

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