Each grief experience is unique, yet we share the need to have it witnessed without someone attempting to lessen it or find ways to reframe it (Brown, 2021).
While grief is typically acute during the early stages of loss, complicated grief is persistent, characterized by a long-lasting preoccupation with the departed.
This is where therapy can offer powerful opportunities for healing. When we’re stuck in specific thoughts and feelings of acute grief, it’s challenging to find a way out of it alone (Brown, 2021; Shear, 2015a).
This article explores complicated grief and introduces treatments and interventions that offer hope for the bereaved.
What Is Complicated Grief in Psychology?
Recent research suggests that grief does not always follow the linear and predictable stages previously thought. It remains broadly accepted that grief is a process that attempts to recover meaning following a loss (Brown, 2021).
Brené Brown (2021) found that grief involves three fundamental elements:
- Loss
While death and separation are central to bereavement loss, other elements include loss of normality, loss of what could be, and loss of what we thought we knew. - Longing
“An involuntary longing for wholeness, for understanding, for meaning, for the opportunity to regain or simply touch what we have lost” (Brown, 2021, p. 111). - Feeling lost
The painful and challenging struggle to reorient physical, emotional, and social worlds.
Psychology defines grief as complicated when intense feelings of sadness, loneliness, fear, anxiety, guilt, resentment, anger, and shame go unresolved. And such complicated grief results from prolonged periods of acute grief (the initial period of loss that dominates life), interfering with the ability to reorient and find new meaning (Brown, 2021).
The experience leaves the bereaved finding it impossible to imagine a future without the loved one; everything else is pointless, and others are left feeling helpless and frustrated (Brown, 2021).
Someone going through such prolonged and intense bereavement requires more than awkward silences or trite responses; they need “connection, for storytelling and story catching” (Brown, 2021, p. 112). They understand, yet can’t accept, what has happened and may see grief as a problem rather than a natural human feeling.
To put it another way, “the person is ‘stuck’ in acute grief and mourning is derailed” (Shear, 2015a, p.4).
8 Risk factors of complicated grief
“Complicated grief poses significant physical, psychological, and economic risks” to the bereaved, caregivers in particular (Mason, Tofthagen, & Buck, 2020, p. 151).
Mason et al. (2020) identified many and varied risk factors that contribute to complicated grief, including:
- Depression
- Anxiety
- Poor physical health
- Maladaptive dependency and attachment traits
- Lower perceived social support
- Family conflict at end-of-life
- Family having difficulty accepting death
- Fewer years of education
Knowledge of such factors is essential and can help guide the support provided by therapists and other mental health professionals.
20+ Symptoms of Complicated Grief
“Sometimes sorrow and yearning seem very strong and stubborn, and a person can’t imagine ever being happy again” (Shear, 2015a, p. 4).
The Center for Prolonged Grief (n.d.) at Columbia describes the following thoughts, feelings, and behaviors as stuck points (both symptoms and factors) that may derail adaptation to loss:
Thoughts and feelings
- Disbelief
- Imagining alternative scenarios
- Caregiver blame or anger
- Judging grief
- Survivor guilt
Behaviors
- Avoiding grief triggers
- Inability to move forward
- Inability to connect with others
People with prolonged or complicated grief may ruminate over such thoughts and feelings, uncomfortable or unwilling to move forward without their loved one. Their behavior gravitates toward and remains focused on avoiding reminders of their loss or escaping their painful reality.
“Complicated grief is like being in an ongoing, heightened state of mourning that keeps you from healing” (Mayo Clinic, 2021).
The Mayo Clinic suggests that the following symptoms can be experienced in initial, acute grief but are prolonged in complicated grief:
- Intense and ongoing sorrow, pain, and rumination resulting from the loss of a loved one
- Difficulty accepting death and ongoing feelings of numbness or detachment
- Bitterness and believing life no longer has purpose or meaning
- Intense and persistent longing for the loved one
- Distrust of others
- Focusing on little, or nothing, else other than the death
- Extreme and ongoing focus on (or avoidance of) reminders of the loved one
- Difficulty performing or maintaining everyday routines
- Isolation and withdrawal from social activities
- Deep experience of depression, guilt, or sadness
- Belief they could have prevented the death
- Wishing they had died along with their loved one
Complicated grief vs depression
“The relationship between depression and bereavement is complicated and often perplexing to even the most seasoned clinicians” (Clark, Iglewicz, & Zisook, 2021). As a result, a diagnosis of depression is typically discouraged during the first two months of grieving.
There are differences too. Grief is often identified through the bereaved person’s preoccupation with thoughts, images, and memories of the deceased. In contrast, someone with major depressive disorder is generally preoccupied with self-critical and pessimistic rumination and feelings of worthlessness (Clark et al., 2021).
Complicated Grief Treatment: 12 Examples
“To heal, people need to wrestle with how to understand that a loved one is gone and what the loss means to them” (Shear, 2015a, p. 4). While it’s essential to retain that connection, the bereaved must find a way to live a meaningful life in the absence of their loved one. It may not be a case of avoiding painful reminders but instead finding the right balance between doing things they used to enjoy together and beginning new ones.
To manage challenges, such as family holidays, weddings, birthdays, and anniversaries, and maintain or regain a sense of control, the therapist must work with the person experiencing complicated grief to (Shear, 2015b):
- Plan for difficult times
It is usually possible to predict when difficult events are likely to happen; planning how to spend that time is vital. - Honor and maintain bonds with the person who died
Death should not end the bonds shared with that person; it is vital to honor them. - Find new and pleasurable activities with those who are left
After loss, it can be challenging (yet remains essential) to identify times of celebration as an opportunity to find joy. - Take care of yourself and let others care too
Clients should have self-compassion, taking care of their needs, allowing themself the time and space to feel sad, and allowing others to take over some of the most stressful activities.
The Mayo Clinic (2021) also suggests that seeking treatment and support for complicated grief is vital, including a focus on the following strategies:
- Stick to the treatment plan
Attending therapy sessions and practicing skills as agreed and planned. - Practice stress management
Finding activities and strategies that remove or reduce stress. - Take care of yourself
Resting, eating well, exercising, and finding time to relax to relieve stress, anxiety, and depression. - Reach out to personal faith systems
Find comfort by engaging with their faith (if they have one). - Socialize
While it’s tempting to avoid others, remaining connected, whether to have fun or to seek support, is crucial. - Acknowledge and plan for special dates
Inevitably, there will be many ‘first’ anniversaries or special dates in the 12 months that follow loss. Planning and finding new ways to celebrate can help. - Learn new skills
Losing a loved one may highlight a lack of skills in certain areas of life. This is the time to learn them, whether through classes or help from friends and family. - Join a support group
Others have been through similar difficult times. A support group can provide the opportunity to share experiences and feelings without the fear of overburdening close family and friends.
6 Worksheets & Workbooks for Therapists
The following worksheets and activities can be helpful during therapy sessions but also as homework (modified from Shear, 2015b; Shear, 2020).
Grieving, Identifying, and Managing Difficult Times
The Grieving, Identifying, and Managing Difficult Times worksheet helps identify events that will be difficult for the grieving person and plan things to do at that time.
While nervousness is to be expected about each new occasion as it gets closer, this worksheet will help the person plan ways to make these occasions enjoyable, practice self-care, and honor the missing person.
Grieving and Monitoring Difficult Times
After losing a loved one, the fear surrounding an upcoming occasion may be worse than the event itself.
Use the Grieving and Monitoring Difficult Times worksheet to keep track of difficult times and monitor their intensity along with positive and negative emotions.
Grief – HEALING Milestones
Grief is complex and has no rules. We may, at times, wonder if we are “doing it right” or “handling it well” and what to expect, especially when experiencing complicated grief (Shear, 2020).
The Grief – HEALING Milestones worksheet can help the therapist and client watch out for milestones (following the acronym HEALING) that are likely to occur.
Consider each of the milestones in relation to the person lost. Reflect on each one and how it can be made positive or more manageable (modified from Shear, 2020).
Grief – Healing DERAILERS
Healing milestones can be experienced at different times and in various ways, and the ability to cope can be derailed (Shear, 2020).
The Grief – Healing DERAILERS worksheet helps clients identify what is derailing their healing process and reflect on how changes can be made.
Consider each of the DERAILERS in the worksheet and think about what can be done to make them less damaging (modified from Shear, 2020).
TEAR – Tasks of Grief
Whether viewed as a process or a set of stages, undoubtedly, the completion of specific, essential tasks can help move the individual through their grief.
Worden (2018) describes the stages as follows:
- Accepting the reality of loss
- Experiencing the pain of that loss
- Adjusting to a new and different life
- Investing in a new reality
The TEAR–Tasks of Grief worksheet helps define the tasks that the bereaved must complete moving through mourning.
Grief – Pillars of Strength
Samuel (2019) suggests focusing on multiple pillars of strength to help overcome grief, including:
- Relationship with the person who has died
- Relationship with oneself
- Ways to express grief
- Time
- Mind and body
- Limits
- Structure
- Focusing
The Grief – Pillars of Strength worksheet helps the bereaved explore each strength pillar, identifying actions that may help them move forward.
Best Assessments, Tests, & Inventories
There are many assessments and tests available for grief, some of which are helpful for complicated grief. We include several below.
The Mayo Clinic (2021) offers a valuable set of questions that prepare the client for how they may be assessed in their therapy sessions:
- How often and how much time do you spend thinking about your loved one?
- Do you feel you could have prevented the death of your loved one?
- How well are you functioning in your daily life?
- Do you wish you had died along with your loved one?
- Have you had trouble eating or sleeping since your loss?
- Are you eating or drinking excessively?
The National Palliative Care Research Center offers a Complicated Grief Assessment to capture how the bereaved person has been feeling over the last month.
3 Best questionnaires
The Grief Intensity Scale by Weill Cornell Medicine’s Center for Research on End-of-Life Care provides a diagnostic tool to assess a person’s risk of developing complicated grief.
The Inventory of Complicated Grief provides another helpful tool for assessing the bereaved’s experience of complicated grief.
Columbia’s Center for Prolonged Grief has a set of symptom-focused questionnaires available to identify and characterize complicated grief.
How to Do Grief Group Therapy: 13 Tips
Complicated grief therapy can effectively treat long-term acute grief when performed in group sessions.
During group therapy, members (modified from Mayo Clinic, 2021):
- Learn about complicated grief and its treatment
- Explore reactions and symptoms to complicated grief
- Learn how to adjust to loss and create new, meaningful life goals
- Take part in imagined conversations with their loved one
- Use visualization to imagine them and provide comfort
- Learn how to identify, explore, and process their thoughts
- Identify and practice coping skills
- Find ways to reduce feelings of guilt, shame, and blame
Grief support groups successfully treat complicated mourning in the following ways (Underwood, 2004):
- Provide members with safety and support, often eroded by traumatic loss
- Provide education regarding the grief process
- Offer normalization and validation regarding the loss and life changes that follow
- Help prepare members for the challenges ahead
- Equip members to problem-solve.
“Effective groups don’t just happen; they require preparation and thought” (Underwood, 2004, p. 296). For that, we recommend a few valuable books below on therapy for complicated grief.
3 Books on Grief Theory & Counseling
There are many helpful grief books on tackling grief inside and outside therapy. The following are three of our favorites.
1. Grief Works: Stories of Life, Death, and Surviving – Julia Samue
Julia Samuel has worked for over 25 years counseling those experiencing grief.
In this insightful, helpful, and heart-warming book, she takes the reader through the experiences of the grieving and provides invaluable advice for those offering support.
Find the book on Amazon.
2. Grief Counseling and Grief Therapy: A Handbook for the Mental Health Practitioner – J. William Worden
This therapy book is an essential resource for those working with the bereaved, from seasoned practitioners to someone new to the field.
Worden introduces the latest research alongside a sensitive yet insightful approach to grief counseling.
Find the book on Amazon.
3. Techniques of Grief Therapy – Robert Neimeyer
This highly valued and practical book covers a variety of therapeutic techniques to support those coping with loss.
Robert Neimeyer offers significant insights and an innovative toolkit for anyone working with clients encountering grief.
Find the book on Amazon.
Helpful Grief Resources From PositivePsychology.com
Grief is often acute during the early stages of loss, and if not dealt with, can become prolonged and complicated. Therapy can provide hope and help to the grieving.
Our free resources include:
- Moving Forward From Grief
Use this tool to encourage clients to reflect on how they would like their lives to look on the other side of grief. - Challenging Unhelpful Thoughts Arising from Grief
Cognitive-Behavioral Therapy, used in this worksheet, can help replace negative thoughts surrounding grief with more positive ones.
The 17 Grief and Bereavement Exercises can be purchased directly or are available with a subscription to the Positive Psychology Toolkit©, but they are described briefly below:
- Taking Care of the Grieving Self
This helpful tool offers a framework to assess your client’s degree of self-care during the grieving process while providing insights into the following domains to encourage mental and physical wellbeing: - Sleep hygiene
- Social Connections
- Body maintenance
- Holistic soothing
- You Are Not Alone in Your Suffering
Working through the following four steps can help bereaved clients understand they are not alone in their suffering and offer comfort in difficult times:
Step one – Recognize common grief symptoms.
Step two – Identify your grief symptoms.
Step three – Reflect on your grief symptoms.
Step four – Answer the set of reflection questions.
A Take-Home Message
While it is natural to think of grief as a set of stages that, while upsetting, must inevitably be moved through, this may not always be the case.
Complicated grief is a prolonged continuation of the initial acute stage. It leaves the bereaved person “stuck,” unable to move forward with their feelings, experiencing numbness, grief, and a disconnection from life’s meaning.
If your client is experiencing a prolonged and deep sense of guilt, depression, or sadness, or the wish to isolate from friends, family, and social occasions, ongoing professional bereavement support is required.
A therapist can help clients understand what it means to have lost their loved one and connect with a new, different, yet still meaningful life. Extra support and awareness will be required when encountering anniversaries – first ones in particular – and encouragement to honor and maintain bonds with their loved ones while moving forward with their lives.
This article offers helpful insights to those experiencing grief or supporting the bereaved as a therapist. The worksheets provide opportunities to work through grief and process the complex and upsetting thoughts and emotions experienced.
