Mary is a widow who sought treatment 18 months after her husband David’s sudden unexpected death of a heart attack. She was referred by her family doctor who was concerned about her physical and emotional health. Mary blamed herself for David’s death because though she had been encouraging him to see his doctor and take some exercise, she had left it up to him to make the appointment. After he died, she was full of self-recrimination. Further, she frequently reminded herself about how terrible it was that she had not been present when David died alone in their bedroom. She became reclusive, took time off work, and began smoking again. Mary had started on a course of antidepressants but after nearly 6 months showed little improvement.

When Mary presented for treatment, her therapist administered a screening questionnaire, the 19-item Inventory of Complicated Grief (ICG) and Mary’s total score of 56 out of a possible 76 was well above the threshold of 30 considered a positive screen for complicated grief (CG). She also completed the Grief-Related Avoidance Questionnaire (GRAQ) and endorsed a total score of 33, a moderately high level of avoidance. She completed the Typical Beliefs Questionnaire (TBQ) that rates problematic grief-related thoughts and beliefs that again indicated symptoms with a total of 56, also a high score.

Mary arrived at her first clinic appointment in a somewhat disheveled state, and she cried copiously during the session. She described a rewarding and very loving relationship with David and their two daughters and stated that life held no interest for her now that he was gone. She hoped to die soon, but would not hurt their daughters by taking her own life. The therapist confirmed that Mary was experiencing prolonged acute grief with strong feelings of yearning, longing, and sadness as well as anxiety about a future without David. She had frequent insistent thoughts of him that were both deeply sorrowful and also warm and comforting. She still could not believe he had died in this way. In addition, Mary showed evidence of grief complications, including ruminative counterfactual thoughts (e.g., “If only I had insisted on his going to the doctor his heart condition would have been diagnosed and he would still be alive”), catastrophic misinterpretation of a future without him (e.g., “My life is over if David is not here.” “If I am not very careful I will forget him.”), and extensive avoidance of reminders of the loss. She could not understand how other family members were “getting on with things.” She was annoyed at people who seemed to be suggesting that she was not trying hard enough, yet she also felt they might somehow be right. Since his death, Mary had not slept in the bedroom she shared with David. She was unable to look at photos of her husband and would not discuss him with their daughters other than to tell them that her heart was broken. She was not attending to self-regulation as evidenced by low levels of self-compassion; by returning to smoking; and by paying little attention to getting good nourishment, enough sleep, adequate exercise, or engaging in pleasurable activities. After completing the rest of her standard assessment, the therapist diagnosed Mary with CG.

The therapist asked Mary to begin using a daily diary to record her grief levels. During the first week, her levels were consistently very high, 9 and 10 on a scale of 0–10. However, during week 2 Mary recorded an 8 and said she was noticing that while her grief was really hard “it was not terrible all of the time.” In the second session, the therapist asked Mary to try to imagine that her grief was at a manageable level and to think about what she would want for herself if that happened. Surprisingly, given her catastrophic thinking about the future, it took little prodding for Mary to explain that she had a wish to complete her education. She also said she had long wanted to take a trip to Italy. She agreed to begin getting information on both aspirational goals, although she said it was unlikely that she would be able to do either without David’s help.

The therapist urged Mary to invite someone to the third session. Initially, she was quite reluctant to do so, but finally agreed to bring her sister, Pauline. As frequently happens in these sessions, Pauline validated the report that Mary and David had enjoyed a very loving and enviable relationship. She also explained that she loved her sister very much, and she was so sad that David had passed in this way, but she felt stymied in trying to support Mary as her calls mostly went unanswered. Pauline said she would help in any way—in fact, it would be a great relief to her if there was anything at all she could do to relieve her sister’s pain. The therapist explained the syndrome of CG and briefly described the planned treatment procedures and their rationale. Pauline offered to be available to meet Mary for coffee after her appointments or to phone her after Mary listened to the recording of the story of the death that she would make as a part of the treatment. Mary was moved by her sister’s offers of support and said she appreciated this very much. She added tearfully that she was not very good at asking for help, but she was very lonely without David.

The fourth session began a sequence of the treatment in which Mary was asked to revisit the story of the death. She found it very difficult to comply when she was asked to close her eyes and imagine herself back at the time when she learned that David had died. However, she completed the exercise as best she could. The story she told was audiotaped, and she took the tape home with a plan to listen daily. However, when the therapist phoned as planned, she said she had not been able to listen to the tape as she feared her grief would be out of control. With gentle encouragement, she tried again and gradually began to engage with the story of receiving a phone call from her daughter who had gone over to the house and found her father. Mary’s grief was hard to witness, and she struggled with the “shoulda, woulda, couldas”. The revisiting sequence continued for 5 weeks; Mary managed to listen to the tape four or five times per week. Her willingness to engage and reflect on the story slowly led to the realization that she was not responsible for David’s death. As she put it, “Sure if his heart was going to give out it made no difference if I was there or not—his time was up.” She was sad that she was not with him and that he was alone when he died, but, on reflection, she came to realize that this, too, was likely not as devastating as she had been imagining. She said she was confident that he knew how much she loved him, and that he might not have even realized that he was dying and if that was so, he would not have missed her. Moreover, even if he had been aware, he would have known that she would have been by his side in the blink of an eye had she known he needed her. These thoughts gave her considerable relief. She began to think that it was up to her to live a full rich life for them both.

The therapist also asked her to begin revisiting things that she was avoiding. They first worked to develop a hierarchy of such situations and then began planning how she could start to go places and do things she was avoiding. This would help her continue to process the loss and allow her to move around more freely in the world. A goal of the planned revisiting exercises was to feel more comfortable being in the bedroom she shared with David. This was very challenging for her to even consider at first, and she admitted sheepishly that a “mad part of me believes he isn’t really dead if I don’t go in.” However, after thinking about this for a number of weeks while revisiting less challenging situations she was also avoiding, she made the decision around week 10 to move back into the bedroom. She told the therapist “I know he’s not there but I feel close to him in here and I remember the happy times we had cuddling up at night.”

Mary and the therapist began working with memories. Mary brought photos of David to the sessions and looked at them for the first time since he died. She said they still made her very sad, but it also felt really good to be able to see him and remember the good times they had together. She shared memories of David with considerable pleasure, struggling to find something negative. She finally settled on his annoying habit of folding the newspaper the wrong way around and reading her out snippets when she preferred to read them herself. She commented that while she found those things irritating at the time, she missed them now. She also noted that he was stubborn and quickly became irritated if he perceived she was nagging. When she talked about this she suddenly remembered that she had, in fact, nagged him about going to the doctor, and he got annoyed with her so she stopped. The final exercise was the imaginal conversation. The therapist invited Mary to imagine that she was with David right after he died, and that even though he truly was gone, she should imagine that she could talk, and he could listen and respond. The therapist suggested that Mary could say anything or ask anything she wished. This was a poignant, bittersweet experience for Mary. She apologized for not being there when he died and beautifully answered for David with: “Mary, my love, you were always there for me.” She said she wished she had made him go to the doctor and allowed herself to hear him reply: “Now Mary, who could ever make me do something I didn’t want to?”.

After completing the 16-session program, Mary had returned to sleeping in her own bedroom, had given up smoking, and had joined a choir, something she was interested in but never pursued because David did not care for singing. She had gone on a short trip to Italy with her daughters and enjoyed it (“but not as much as I would have with David”). She had collected all the documentation for returning to school but did not yet feel ready to apply to a program. Mary thought about what had been most helpful in opening the way for these positive changes. She said the imaginal revisiting (“I never thought I would be able to think about his dying without going crazy”) and the conversation with David where he had imaginally acknowledged that she had been there for him throughout their marriage, and he was too stubborn to go to the doctor. She still missed him and reckoned she always would, but was now engaging in life again, accepting some social invitations and enjoying time with her newest grandson, who had been named after David and was stubborn just like him. At the last session, she produced a note that someone had written saying: “you can grieve that he is gone or rejoice that he was” and declared that was what she was going to try to do from now on. Mary continues to miss her husband, but her grief is back on track to find its rightful place in her life. She can remember and think about him with warmth and pleasure, though always with a tinge of sorrow. Her memories contain her love and with it her yearning and sorrow. She has come to understand that grief is the form love takes when someone we love dies.

Mary’s story illustrates the syndrome of CG , a condition that is gradually becoming better recognized and for which targeted treatments have now been devised. The remainder of this chapter describes the syndrome of CG and an innovative efficacy-tested treatment called complicated grief treatment (CGT) . We outline the principles and procedures used to develop this treatment and briefly describe building blocks upon which it rests.

The term CG is used to describe a syndrome consisting of acute grief symptoms that persist beyond the time frame that is considered adaptive or culturally appropriate in the bereaved person’s social network accompanied by complicating thoughts, feelings, and behaviors. Acute grief is the result of a destabilized attachment system (acute attachment insecurity) in which the attachment behavioral system is activated while caregiving and exploratory systems are inhibited. The configuration and course of grief is different for each person and each loss. Nevertheless, we can still identify generic symptoms of acute grief based on the instinctive response to attachment loss.

Typical symptoms of bereavement-induced acute attachment insecurity include separation distress with intense yearning, longing or searching, preoccupation with thoughts and memories of the lost person that frequently include hallucinatory experiences, pronounced feelings of emotional loneliness, feelings of emptiness and anxiety about a future without that person, feelings of mistrust and detachment from others, and feelings of anger at being abandoned. Caregiver inhibition in the setting of loss is often associated with a sense of caregiver failure. Feelings of guilt or remorse are common, and there is sometimes shame. Self-blaming thoughts may accompany feelings of caregiver ineffectiveness. Exploratory system inhibition in adults produces feelings of incompetence and disinterest in learning and performing in the world. By definition, bereavement entails confrontation with death which may trigger a trauma response with feelings of shock and disbelief and a sense of confusion and disorientation .

Acute grief is variable with respect to the specific symptoms it entails and the time course over which it is transformed and integrated. However, for most people, acute grief does not last indefinitely. Like physical wound healing that takes differing amounts of time and has varying residual impairment based upon the nature of the wound, the health of the person who suffers that wound, and the availability of support and care, healing after loss is variable in its course based on similar considerations. Wound healing can be complicated by an infection or a compromised immune or cardiovascular system. Healing after loss can be complicated by thoughts, feelings, or behaviors that derail the natural process of adaptation. People we love are deeply interwoven in our lives. Essentially, they become a part of us, and when they die, we must make many adjustments in order to adapt to their loss. These adjustments can be generally grouped as loss-related and restoration-related. For most of our lives, we inhabit the present feeling connected to the past and ready for the future. We move through time bringing supplies from the past and inventing our future in ways that seem so natural that we do not notice that we are doing this. Bereavement disrupts this reassuring sense of continuity making the past seem lost and invention of the future challenging or even impossible. It is as though an earthquake has struck, and we are suddenly stranded on a path with the way back blocked and the way forward across a seemingly impassable chasm. The adaptation process requires us to reclaim supply lines from the past and find a way to bridge the chasm so we can move forward .

In order to reconnect to the past, we first need to learn what the finality and consequences of the death means to us. We must reconfigure our internalized relationship with the person who died and reenvision our lives going forward in a way that has purpose and meaning and possibilities for joy and satisfaction. We need to live in a world without the deceased person, observing and reflecting upon what that is like. We need to begin to imagine ways we can feel enthusiastic about the future. Adapting to bereavement is fundamentally a learning process that takes place in a setting of intense emotional activation and takes place best when emotions are adequately regulated. Adaptation can get derailed. Rumination and/or avoidance can complicate grief and hinder the learning process. So too can an inability to regulate intensely painful emotions.

When complications derail the progress of grief, the result is a repetitive loop where feelings of intense yearning, longing, and sorrow persist along with frequent insistent thoughts of the deceased often accompanied by frustration of endless pain; bitterness about the loss, anger, or disappointment with oneself, with others, or with the unfairness of the world; or a belief that it is wrong to now enjoy life. Concurrently, the bereaved person eschews a myriad of reminders that the person is gone. They may stay away from the final resting place, shun activities once shared with the deceased, refrain from disposing of possessions, or avoid countless other reminders. Counterfactual rumination and avoidance prevent the bereaved person from coming to terms with the finality and consequences of the loss. Instead of finding a way to integrate the painful information, they remain caught in a cycle in which the death seems to have been wrong, unfair, or even preventable. The mental representation of the deceased is not revised, and life goals are not reviewed or redefined .

The number of people who develop CG ranges from an overall population estimate of 2.4–4.8 to 10–20 % for spousal bereavement (Prigerson, 2004) to even higher rates for loss of a child (Meert et al 2011) . Neimeyer and Burke (2013) points out that in considering risk of CG, clinicians need to “consider both fixed and relatively enduring characteristics of the survivor and shifting or circumstantial factors that bear on his/her ability to adapt to the death of a loved one.” Their review of prospective risk factors for developing CG include background factors (close kinship, female gender, insecure attachment style), death-related factors (bereavement overload, violent death, low acceptance of pending death), and treatment-related factors (caregiver burden, aggressive medical intervention, family conflict regarding treatment). It is important to remember in any risk assessment that the presence of risk factors does not always predict CG, and the absence of risk factors does not preclude the development of CG. CG can be identified using a standardized tool such as the ICG (Prigerson et al., 1995) along with a detailed clinical interview (Shear, 2015) .