CGT treatment (CGT) is a 16-session psychotherapy model that is delivered in three phases consisting of a beginning, middle, and termination; see Figure 12.1). In the beginning phase the therapist provides an introduction to the treatment model, in which grief is understood to be a natural inborn, biopsychosocial pathway to adjustment to a painful loss. Characteristic features of grief are reflections of separation distress and traumatic distress, manifested in various ways that can be influenced by cultural practice. The trajectory of natural grief is to move from an engrossing primary state in which grief exerts a psychological and emotional preeminence to an integrat-
TABLE 12.1. Items Rated on the Inventory of Complicated Grief
1. I think about this person so much that it's hard for me to do the things I normally do.
2. Memories of the person who died upset me.
3. I feel I cannot accept the death of the person who died.
4. I feel myself longing for the person who died.
5. I feel drawn to places and things associated with the person who died.
6. I can't help feeling angry about his/her death.
7. I feel disbelief over what happened.
8. I feel stunned or dazed over what happened.
9. Ever since he/she died it is hard for me to trust people.
10. Ever since he/she died I feel like I have lost the ability to care about other people or I feel distant from people I care about.
11. I have pain in the same area of my body or have some of the same symptoms as the person who died.
12. I go out of my way to avoid reminders of the person who died.
13. I feel that life is empty without the person who died.
14. I hear the voice of the person who died speak to me.
15. I see the person who died stand before me.
16. I feel that it is unfair that I should live when this person died.
17. I feel bitter over this person's death.
18. I feel envious of others who have not lost someone close.
19. I feel lonely a great deal of the time ever since he/she died.
Introduction and rapport building History of relationship, loss, and grief Introduction to the treatment model and procedures Introduction to personal goals work
LOSS FOCUS Grief monitoring Imaginal revisiting Cognitive work Situational revisiting Memories work Imaginal conversation with the deceased
RESTORATION FOCUS Goals work Situational revisiting Interpersonal work
Discussion of treatment progress
Plans for reinforcing and continuing progress
Feelings about termination of treatment
FIGURE 12.1. Overview of the structure of CGT.
ed state of subdued background grief, that continues to evolve and change. The process by which this transition is achieved has been usefully described as the "dual process model" of coping (Stroebe & Schut, 2000). Bereaved individuals are seen as entering an oscillating state of loss-focused and restoration-focused coping. Such oscillation is seen as the optimal way for treatment to proceed in CGT. The goal of CGT is to help a person create a state of integrated grief.
Integrated grief is a part of the life of the bereaved individual. Many people experience a sense of disbelief in the immediate aftermath of the death of someone to whom they were very close. Even if the death is expected, loss of a loved one can be an intense experience for the bereaved family and friends. Often there is a period (variable in length) of intense emotions, primarily sadness, and sometimes guilt, anger and/or fear. Thoughts and images of the deceased typically flood the mind of those left behind. For most people, there is a period of turning inward, away from the hustle and bustle of everyday life. Many cultures support this period of withdrawal, which may provide an optimal context from which progression of grief can occur. In most people this progression happens naturally, eventuating in a muted, integrated form of grief. There is some indication that movement out of a primary grief state is facilitated by meaning-making experiences or activities and by positive emotions (optimism, compassion, acceptance, and forgiveness).
Once achieved, integrated grief can be a positive force in a person's life, providing a meaningful lifelong link to an important relationship. Rather than promoting detachment from the deceased, integrated grief is accompanied by a reconfigured relationship to the loved one. Grief contains within it personal implications of the death of the loved one for the bereaved individual, and these typically change over time. As an example of this, a leading author in the field, Robert Neimeyer (a prominent thanatology researcher and editor of the journal Death Studies), wrote the following:
Many of the subsequent emotional, relational and occupational choices made by my mother, my brother, my little sister, and me can be read as responses to my father's fateful decision [to commit suicide], although their meaning continues to be clarified, ambiguated, and reformulated across the years. (2001, p. xi)
CG is a maladaptive grief reaction that can be conceptualized as a state of being "stuck" in primary grief. Rather than taking its place in the background, integrated into the life of the bereaved person, CG remains "center stage." Instead of providing a link to a positive, nurturing relationship, this form of grief is focused on reminders of a terrible loss. Consequently, the person experiencing CG continually feels as if the death happened very recently, even though many months or even years have passed since its actual occurrence. CG interferes with the natural ability to feel a positive connection to the deceased, because attention is focused on the magnitude and pain of the loss. People experiencing CG typically feel estranged from others and unable to feel satisfaction or interest in daily activities.
CGT is conceptualized as an intervention that seeks to remove impediments to the progression of primary grief and facilitate integration of loss-related thoughts and feelings into the mental and emotional life of the bereaved. Impediments include dysphoric emotions and problematic attitudes or beliefs about the death. CGT targets blocked positive as well as negative emotions and seeks to relieve guilt about positive as well as negative emotions. For the person with CG, the event of the death was a psychological trauma that has led to a PTSD-like reaction. Thus techniques to relieve traumatic distress are a key augmentation component of CGT. Difficulty feeling a positive connection to the deceased and yearning and longing for the lost relationship are forms of separation distress. Several components of CGT target this problem. In addition, given that positive emotions of optimism, compassion, acceptance, and forgiveness contribute to a favorable outcome in natural grief, we seek to develop and enhance these. As noted above, reports in the literature support the idea that a deficiency of positive emotions is associated with prolonged, intense grief (Bonanno, 2001; Lindstrom, 2002), as is an excess of negative emotions. CGT identifies putative sources of enhanced negative emotions and diminished positive ones as treatment targets.
The CGT model considers that adjustment to a loss requires a vision of the world that includes a potential for gratification even without the physical presence of the deceased. However, we do not consider psychological detachment as the goal of successful grief. Instead, the CGT therapist works to facilitate integration of the relationship to the deceased into current and future life, while encouraging development of satisfying personal goals and relationships. The therapist helps the patient reestablish interests and relationships, taking the position that the relationship to the deceased is ongoing in memory, and that memory is not a static entity but rather a living, dynamic process. As eloquently described by Buechner (1991) and Neimeyer (2001), a person we love continues to live with us, even after he or she dies, and to influence our lives forever. Thus the emphasis in CGT is on helping the bereaved person to live fully again, "accompanied" by the deceased person alive in memory.
A novel component of CGT entails a focus on long-term personal goals and discussion of ways to achieve them. This segment is a component of the restoration-focus strategy in CGT. Motivation to go on living can be a problem for individuals with CG. We have documented suicidal ideation in more than half of the individuals with CG whom we have treated, and nearly a third have either made a suicide attempt or engaged in indirect self-destructive behavior. in addition, a kind of reluctance to give up grieving is often seen in CG. The person with CG often fears that grief is all that is left of the relationship to the deceased and if he or she has less grief, then he or she risks losing the deceased forever. Survivor guilt about still being alive and free to enjoy the world may also be present. There may be reticence to develop a close relationship because of fear of being hurt again by its loss. Some people are convinced that no one can understand them, or they feel resentment because they experience others as pushing them to relinquish guilty or angry or sad feelings before they are ready. Still others are very afraid or ashamed of their own emotions. Thus we have learned that it is a good idea to address ambivalence about changing right from the beginning. To do this, we draw upon motivational enhancement strategies.
The primary motivational enhancement strategy we use is that of personal goals work. CGT uses a modified motivational interviewing approach to elicit, discuss, and monitor progress of personal goals, beyond grief. The therapist helps the patient consider things that he or she would like to be doing if he or she were no longer grieving. This exercise conveys to the patient that the therapist (1) believes it is possible for this person to feel less pain from grief, (2) finds less painful grief perfectly acceptable, even desirable, and (3) considers the life of the bereaved person to be important, completely apart from his or her grief and loss. The procedure used encourages patients to identify their own life goals. Sometimes it is surprising how ready patients are to do this. other times, several sessions are required before goals are elicited. once identified, the therapist invites patients to identify specific ways they would know if a given goal were accomplished, how com mitted they are to their goal, what stands in their way (other than grief), and who can help them achieve their goal. Goals work is introduced early in the treatment, usually at the second session. Thereafter, the therapist monitors progress toward goals and discusses strategies and achievements with patients. In implementing this component we were surprised to find that many people with CG do harbor such goals. Even in early sessions, an individual's affect becomes noticeably more positive as he or she focuses full attention on the discussion of personal goals and dreams.
CGT includes a structured procedure for revisiting the death and surrounding events, using a procedure similar to that developed by Foa and colleagues (Foa, 1995) for the treatment of PTSD following rape and other types of trauma. This technique was initially based upon research documenting anxiety reduction during prolonged exposure to fear cues. It is clear how this procedure can be useful in PTSD; it is somewhat less clear in complicated grief, because grief comprises a more complex emotional reaction in which fear is not predominant. However, many people struggling with grief are very frightened of talking about the death. The imaginal revisiting exercise helps ameliorate this fear. Moreover, Foa has found that prolonged exposure is a powerful way to facilitate the evolution of new ways of thinking about the trauma. We have observed this improvement as well in grief treatments. Most striking is the way in which this exercise seems to enhance the patient's nonjudgmental acceptance of the death. By using Foa's technique of tape recording and relistening to the story, the patient sees clearly how the story evolves and often notices aspects of his or her own story that he or she has not attended to previously. For example, some patients come to the realization that there were many very supportive people present at the time of the death. Others notice how helpful they really were in comforting or taking care of the deceased. Still others find that they are reassured about how little the person they loved suffered at the time of the death. Thus a key procedure in CGT is modified use of the procedure that Foa and her colleagues referred to as "prolonged exposure." For grief treatment we call this procedure "revisiting." We chose this name deliberately, as described below.
The revisiting procedure entails asking the patient to tell and retell the story of the death, eventually focusing on the most painful moments. The therapist gradually encourages disclosure of all emotionally relevant details. For bereaved individuals, the initial exercises of imaginal revisiting are often very frightening as well as intensely painful, but with repetition we have found that the fear diminishes noticeably and this diminishment reduces the pain of other emotions as well. Later revisiting exercises can then focus on the most intensely emotional thoughts and memories. Accompanying reduction in emotional intensity achieved through successful revisiting, a more satisfactory narrative of the death usually emerges. There is also a decrease in the sense of confusion and disbelief. The process of repeated revisiting facilitates acceptance of the death and clarification of problematic expectations and beliefs underlying associated emotions. The death becomes "thinkable"
and looms less large on the landscape of the overall relationship to the deceased.
There are several reasons why we chose the term "revisiting" for this procedure. We wanted to change the terminology because we found that the idea of reliving the death is very frightening to most bereaved people. Moreover, we believe the exercise is not accurately described as "reliving" or "reexperiencing" because it really entails repeatedly activating ("revisiting") a memory. The goal is to work on solving a problem related to the death. Often in solving problems it is helpful to think about the problem, leave it for a while, and then revisit it. in this sense we are revisiting the problem of the death in CGT. "Visitation" is also a term we use when referring to a time to honor the person who died and a time to comfort the bereaved. Revisiting is meant to provide another opportunity to honor the dead and to be comforted, now by the therapist.
During revisiting exercises, specific beliefs that trigger guilt, anger, shame, and fear emerge and are reevaluated. Beliefs such as "I will fall apart," "I will start to cry and never stop," or "I will be shunned and ostracized when I confront the strong emotions of my grief' are proved erroneous when these feared outcomes do not occur. The belief that negative feelings will continue at unbearably high levels, unabated and intolerable, unless the patient avoids talking about the death, is also proven wrong. The overall experience of being able to face painful emotions helps to correct these fears and to reduce denigration of self as weak or "wimpy." Thus imaginal revisiting of the loved one's death is a highly effective and useful technique.
Also important is an extensive debriefing period following each revisiting exercise, during which the therapist guides the patient in techniques to reduce emotional distress and refocus on the present. unlike interpersonal psychotherapy (IPT), in which the therapist is instructed to simply listen when the patient is experiencing very intense emotion, in CGT the therapist is instructed to work with the patient on active techniques to reduce the emotion. The CGT therapist is interested in helping the patient see that he or she has the control to think about the death and also to set it aside. For example, the patient is asked to imagine that the story he or she has told is on a video cassette, and that he or she is rewinding the cassette and putting it away. The therapist then guides the patient in refocusing attention elsewhere. The conversation moves to the topic of plans for the rest of the day or the week, and to a discussion of other people in the patient's life. The therapist explains that part of the effectiveness of revisiting as a problemsolving strategy is to leave the problem for a while. In addition, because the person has been willing to undergo tremendous pain in order to revisit the death in the spirit of honoring the deceased, it is important to acknowledge this effort and make plans to take proper care of him- or herself.
Another component of CGT is situational revisiting exercises. This intervention bears some resemblance to the in vivo exposure technique used in PTSD and other anxiety disorder treatments. Situational revisiting focuses on identifying and confronting situations and people that have been actively avoided, neglected, or shunned since the death. Often avoidance behaviors in bereavement are subtle and not immediately recognized. Still, they can contribute substantially to impairment and to the sense of incompetence and isolation. Avoidance can also interfere with resolution of emotions. Major treatment goals are to reduce intensity of grief-related emotions and to decrease isolation. Thus, the therapist uses situational revisiting to help the bereaved person identify interesting activities and again form satisfying relationships, including reestablishing relationships that have been neglected. However, it is important to be aware that shunning situations that evoke painful emotions is common and can be adaptive. Oscillation between avoidance and confrontation is often very helpful in coming to terms with an unthinkable reality and/or solving a difficult problem. To be effective, however, this oscillation requires a delicate balance, because the relief that ensues from turning away from the evocative situation can serve to reinforce avoidance, particularly if repeated confrontation does not result in lessening of emotion or movement toward problem solving. In this situation the reinforcing relief gradually renders avoidance an ingrained habit.
For individuals with CG, avoidance of activities and places can interfere considerably with adaptive adjustment to the loss and can lead to negative consequences such as a self-concept of incompetence and/or a view of the world as hostile. Avoidance also interferes with the task of resolving the emotional pain in order to find comfort in memories of the deceased. At the same time, avoidance can be helpful in allowing people to focus attention on their current lives and begin to derive life-sustaining pleasure and satisfaction despite the absence of the loved one. Therefore, the therapist needs to find a workable balance between fostering needed contact with evocative stimuli and focusing elsewhere. CGT incorporates exercises focused specifically on revisiting activities, places, and people that the patient has eschewed. Revisiting focuses primarily on situations that the patient would like to do but finds too painful. This exercise helps to reinstate the normal oscillatory process, and the therapist intervenes to facilitate the consequent reduction in affect and problem-solving increase in effectiveness. Revisiting ,in and of itself, can enhance feelings of competence, especially for places patients want to be free to visit, activities they wish to engage in, and people they want to see. Situational revisiting that focuses on enjoyable activities can be a powerful antidote to thoughts of never again being able to experience joy or satisfaction without the loved one.
It is worth noting that many individuals with CG have a problem with preoccupation with the deceased. At first blush, preoccupation with the deceased may seem to be the antithesis of avoidance. However, in reality this is not the case. Preoccupation often this takes the form of lengthy, dreamy reveries that focus on idealized moments in the relationship with the deceased. Such behaviors actually resemble avoidance in that they temporarily protect the bereaved person from feelings of loss, and they also pre vent the person from engaging in satisfying activities and forming new relationships.
CGT seeks to enhance patients' ability to access positive, comforting memories of the deceased. it is helpful to be at ease with negative memories as well. For individuals with CG, intrusive memories or images of the death are usually dominant, to the exclusion of a wider access to long-term memories. Sometimes good memories become easily available once grief intensity is reduced through imaginal and in vivo revisiting exercises. However, specific work on memories is also done in CGT. The CGT therapist uses a set of simple forms to facilitate accessibility of memories. Administered over a 5- to 6-week period, beginning after two imaginal revisiting sessions, these forms focus initially on positive, comforting memories. Later, the patient is invited to review "least favorite" memories and things that were annoying about the person who died. Some patients tell us these memory forms were the most helpful component of the treatment. of note, we have found that memory forms are difficult to use before several sessions of the imaginal revisiting exercises have been completed. The positive memories evoke too much sadness if used early.
Imaginal conversation is a technique used in the second half of CGT. The exercise is structured in a manner similar to imaginal revisiting. However, instead of reporting the memory of events related to the death, we invite patients to imagine that they are with the deceased after the death. if they were present at a natural illness-related death, the conversation is held immediately after the person died. very often, distressed, bereaved patients comment that they very much wish they could have had one last conversation with the deceased. Usually they have questions they would like answered and/or things they wanted to say but did not have the opportunity to express. We have found that such questions can be answered very effectively in an imaginal conversation with the deceased.
The therapist is instructed to invite patients to talk with the deceased. Patients are instructed to close their eyes and imagine they are with the deceased after the death, telling the loved one anything they wish, including asking any questions. Then patients are instructed to imagine (pretend) that the deceased can actually hear them and respond. Then patients are invited to take the role of the person who died, and to answer.
This exercise helps bereaved individuals feel a sense of connection with the deceased—which, in turn, provides experiential evidence for the idea that a strong sense of the loved one is internalized. In successfully undertaking this exercise, patients report that it seems much clearer to them how the loved one still resides within them. Patients frequently report that having this "conversation" is very powerful—that it makes them feel a sense of deep attachment to the person who died.
This exercise further facilitates a connection with the loving side of the deceased because the questions are usually ones that cause the bereaved person pain, and the responses are invariably comforting. For example, "Did you feel I abandoned you because I was not there when you died?" The response might be, "Of course, not. I never doubted for a minute that you love me very much and that you would have been there if you could have." Although this may be the response the patient most wants to hear, it is also very convincing that the loved one would have, in fact, responded in this way. The relationship to the deceased for CG patients is virtually always a very positive and loving one. Even when there were difficulties in the relationship, the strength of its constructive, loving side is clear. Recall that CGT seeks to enhance this positive connection rather than encourage disengagement. The imaginal conversation serves this purpose very well. This technique has proven to be extremely powerful when administered at the right time in the treatment.
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