J Rat-Emo Cognitive-Behav Ther (2017) 35:6–25

DOI 10.1007/s10942-016-0242-2

Complicated Grief Treatment: An Evidence-Based

Approach to Grief Therapy

M. Katherine Shear1,2 • Colleen Gribbin Bloom1

Published online: 24 May 2016

Springer Science+Business Media New York 2016

Abstract Complicated grief is a condition that occurs when something impedes the
process of adapting to a loss. The core symptoms include intense and prolonged yearning,
longing and sorrow, frequent insistent thoughts of the deceased and difficulty accepting
the painful reality of the death or imagining a future with purpose and meaning. Com-
plicated grief can cause substantial distress and impairment and it is important that
clinicians learn to recognize and treat this condition. Complicated grief treatment is a
16-session evidence-based psychotherapy developed to release and facilitate a bereaved
person’s natural adaptive response. The current paper clarifies the conceptual underpin-
nings of this approach, provides a description of the major treatment components,
structure of each session, and suggestions for how clinicians can use the treatment to help
clients suffering from complicated grief. A case example is also included to illustrate this
discussion.

Keywords Bereavement Loss Complicated grief Psychotherapy Treatment

Introduction

Bereavement is one of life’s most difficult experiences yet most people find ways to
adapt to even the most painful loss. Research over the past few decades indicates
that the adaptation process can sometimes go awry. However because grief-related
distress and impairment in functioning can continue over a prolonged period there is
continuing debate about when and how to identify maladaptive grief reactions.

& M. Katherine Shear

[email protected]
1
Columbia University School of Social Work, New York, NY 10027, USA
2
Department of Psychiatry, Columbia University College of Physicians and Surgeons,
New York, NY, USA

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Holly Prigerson has led an effort to define a syndrome characterized by grief that is
inordinately prolonged and intense (Prigerson et al. 1995). Based on her valid
reliable method for identifying this syndrome, our group developed and tested a
treatment that we named complicated grief treatment (CGT). This paper describes
CGT and suggests a clinical approach to recognizing people who might benefit from
this approach. A case example is included to illustrate this discussion.
Complicated grief treatment (CGT) has now been tested under 5 NIMH-funded
grants including an initial study published in 2005, a second study targeting older
adults published in 2014 and a third, multicenter collaborative study recently
completed and submitted for publication (Shear et al. 2001, 2005, 2014). Dr. Julie
Wetherell, an experienced CBT researcher, served as a therapist and supervisor for
the collaborative study. She independently published a useful outline of our CGT
manual with comments from her perspective (Wetherell 2012). The current paper
builds on her excellent publication and is structured similarly. In addition it clarifies
conceptual underpinnings of CGT, provides a description of the treatment model
and aims, a summary of major treatment components and suggestions about how
these can be used by clinicians. These additional elements as well as further
clarification of treatment procedures should be helpful to therapists.

Background

The central premise of CGT is that bereavement is a universal life event and that
grief and adaptation to loss are natural inborn responses. Notwithstanding this
universality each close relationship is unique and correspondingly, so is each grief
experience. The elements of grief are shaped by who we lost and what that
relationship meant to us. We grieve differently for each person we lose. Grief is also
shaped by who we are, by our prior experiences and by the world in which we live.
The common dictum ‘‘we all grieve in our own way’’ is clearly true. Nevertheless
there are commonalities in grief including its core components and its eventual
transformation. More specifically, grief almost always contains elements of
yearning, longing and sorrow and thoughts and memories of the person who died
and the quality and intensity of these thoughts and feelings change as we adapt to
the world without our loved one (Shear 2015).
Acute grief is often intense and highly emotional, dominating our minds and
disrupting our lives. Over time the intensity usually attenuates as we come to accept
the unwanted reality, reorganize our internal relationship to the person who died and
envision ways to live a fulfilling life in a world without them. Acclimating to a loss
is facilitated by effective emotion regulation, commonly achieved by finding a
balance between confronting the painful reality and setting it aside, by practicing
self-compassion and by attending to self-determination needs of autonomy,
competence and relatedness. A balance of solitude and openness to comfort from
others also facilitates coming to terms with a loss. Adaptation goes on both in and
out of awareness, fueled by ever increasing understanding of our loved one’s
absence. Adapting to a loss does not change the reality of the loss but it does change
the quality of grief. The permanence of death is mirrored by the permanence of

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grief. We never forget our loved ones nor do we fully stop wanting them or feeling
sorrow that they are gone. However the form and intensity of our yearning and
sorrow usually evolves and matures over time as grief seeks its rightful place in our
lives. This usually means that thoughts and feelings about the loss decrease in
frequency and intensity.
Complicated grief is a condition in which manifestations of grief continue to
dominate a person’s life because something impedes the process of adapting to the
loss (Shear 2012). Complicating thoughts, feelings and/or behaviors (Eisma et al.
2013; Boelen et al. 2015) interfere with the process of accepting the reality of the
loss, redefining the relationship with the deceased person or envisioning a
meaningful future (Maccallum and Bryant 2011). This kind of interference
commonly occurs when a bereaved person gets caught up in counter-factual, self-
questioning second-guessing thoughts, or spends n excessive amount of time in
efforts to escape from the painful reality, such as daydreaming or excessive focus on
hearing, seeing, touching or smelling things to feel close to the deceased can make it
difficult to revise the relationship to the deceased. Excessive avoidance of reminders
of the loss can also do this. The central premise of CGT is that a natural adaptive
process is present in people with complicated grief but is being blocked. The
overarching goal of the treatment is to release and facilitate the bereaved person’s
natural adaptive process (Shear 2015).
The knowledge base on which CGT is built includes findings from bereavement
research (Stroebe and Schut 1999; Bonanno and Kaltman 1999; Bonanno et al. 2005;
Neimeyer 2012; Neimeyer et al. 2014) as well as empirically supported principles from
attachment theory (Bowlby 1982; Mikulincer and Shaver 1998; Mikulincer et al. 2011),
positive psychology, self-determination theory (Ryan and Deci 2000), psychological
immunity (Gilbert and Wilson 2000), self-compassion (Neff 2009), self-psychol-
ogy(Aron et al. 1992; Chen et al. 2011), and learning theory (Tye et al. 2010; Sun et al.
2011). In addition, we use strategies and procedures from other evidence-based
psychotherapies (CBT (Malkinson 1996; Foa and Rothbaum 1998), IPT(Weissman
et al. 2000), MI (Miller and Rollnick 2002), EFT(Greenberg and Paivio 1997), positive
psychology (Aschbacher et al. 2012; Folkman and Moskowitz 2000) modifying them to
address the targets of resolving complications and facilitating adaptation.

Overview of CGT

CGT is a structured intervention that is typically administered in 16 weekly sessions

organized in four phases: (1) Getting started, (2) Core revisiting sequence, (3)
Midcourse review and (4) Closing sequence. The therapeutic stance in CGT is one
in which we acknowledge companionship that derives from the shared human
experience of loss and grief. We consider grief to be the form love takes when
someone we love dies and we honor its myriad forms and waxing and waning
intensity as it seeks its rightful place in a bereaved person’s life. The therapist serves
as a Sherpa-like guide who accompanies clients as a companion as they grapple with
accepting the finality and consequences of the loss, establishing meaningful
continuing bonds with the deceased and finding a ‘‘new normal’’ in which happiness

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is again possible. The therapist contributes knowledge of the terrain of loss and grief
and the ability to design pathways, recognize obstacles and provide tools and
resources to aid in the journey. In serving these functions though, the therapist is
cognizant of the need for the client to find her or his own ways of moving through
the adaptive processes and the therapist intervenes only when necessary. People
with CG feel lost, confused and exhausted by unfamiliar and uncontrollable feelings
and an inability to imagine a future with any possibility of happiness. They are
relieved when they find a therapist who is open and present to their unique story of
love and grief, understands the commonalities in grief and provides a sense of hope
comforts them. Given this orientation, treatment sessions are designed to be present
with clients as they confront the painful reality, to encourage them to spend some
time focusing on the future in a positive way, and to monitor and support clients’
progress, most of which takes place outside of the session. Planning activities for the
upcoming week is an important focus of the session as is motivating the client to do
these. Generally what clients do during the interval between sessions is more
important than what they do in the sessions.
CGT is a structured approach. We do not sacrifice empathy or the importance of
bearing witness to sorrow, but we offer a structure for understanding grief and
adaptation to loss. We gently guide and direct the attention of the bereaved person to
a series of exercises that can help them move forward. We structure sessions such
that each includes a review of the past week, a focus on some aspect of the loss, a
focus on some aspect of restoration of a meaningful future, and a summary and plan
for the upcoming week. Administration of CGT is intended to be personalized to
meet individual needs. The best way to deliver this treatment is to find a middle
ground in which you are neither following exactly the highly specified session
outlines in the treatment manual nor ignoring session instructions to focus solely on
tracking the individual person. The case example provided in this paper includes
illustrations of some ways to do this.
There are seven core components of CGT including three thematic components
interwoven into four procedural ones. Thematic components include: (1) sharing
information, (2) promoting self-observation and self-regulation and (3) rebuilding
connection. Procedural components include (1) advancing aspirational goals and
rewarding activities, (2) revisiting the story of the death, (3) revisiting a world
changed by loss and (4) fostering continuing bonds through living memories.
Thematic components are introduced during the phase we call ‘‘Getting Started’’.
Session 1 is focused largely on inviting the bereaved person to talk about her or his
own life, relationship with the person who died and grief since the loss. Self-
observation is introduced at the end of session one in the form of a grief monitoring
diary and this is continued throughout the treatment. Session 2 is largely focused on
providing information about love, loss and grief to the client. In Session 3 we begin
the process of rebuilding connections by encouraging the client to invite a close
friend or family member to join the session and exploring the possibility that this
person might serve as a confidant and companion in grief.
Aspirational goals work begins in Session 2 and continues throughout the
treatment. Session 4 begins the core revisiting sequence by introducing our imaginal
revisiting exercise in which the client and therapist review the story of learning

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about the death. Session 5 begins work on avoidance of reminders of the loss that
entails plans to confront these in a graded manner. Session 6 begins a discussion of
memories of the person who died and Session 11 or 12 includes an imaginal
conversation with the deceased. Taken together these procedural components foster
acceptance of the finality and consequences of the loss, elaboration of a continuing
bond to the person who died and consideration of ways that ongoing life might have
possibilities for joy and satisfaction. The remainder of this paper is a session-by-
session overview of CGT and a case example.

Getting Started: Sessions 1–3

The objectives of this introductory phase are to (1) Establish a companionship

alliance, (2) Understand the client’s loss in the context of their life history, (3)
Provide information about CG and CGT, (4) Begin grief monitoring and weekly
plans, (5) Begin work on personal aspirational goals and (6) Meet with the client
and a significant other

Session 1

The session begins with introductions, including a brief introduction of the therapist
that fosters a sense of companionship. Then the therapist sets an agenda that include
an overview of the client’s important relationships including a brief discussion of
early family relationships and current close relationships. The agenda also includes
a brief discussion of important interests and achievements in the client’s life and
currently. The remainder of the session focuses on the relationship with the
deceased, the story of the death, and the client’s experience of grief. We suggest
using a set of questionnaires available at www.complicatedgrief.columbia.edu as a
part of the review of grief. The session ends with a brief summary of highlights by
the therapists, feedback from the client and introduction of the grief monitoring
diary and the CG handout.

Weekly plans Activities for the week include daily grief monitoring (diary
available through the center for complicated grief) and reading and reflecting on
the CG handout.

Session 2

The session begins with a review of the past week and setting of an agenda. Review
of the grief monitoring diary (GMD) is brief and entails only noticing when grief
was high and low. The main purpose of this instrument is to encourage self-
observation and reflection and to help clients observe the natural ebb and flow of
grief intensity. The therapist then initiates a discussion of love, loss and grief and
describes the idea of CG as the condition that results when something impedes the
natural adaptation to loss. This discussion is conducted in a collaborative and

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companioning manner that includes provision of a personalized formulation (see

Fig. 1 for an example of the formulation for Grace). The session moves to a
discussion of the goals, procedures and rationale for CGT. About 10 min before the
session ends, the therapist shifts gears and asks the client to imagine what s/he
would want for herself if her grief was at a manageable level. They discuss this for a
few minutes and end the session with summary highlights, feedback and plans for
the upcoming week.

Weekly plans Activities for the week include daily grief monitoring and continued
work on aspirational goals.

Session 3

This session is held with a significant other. The goals are to get another perspective
on the client’s situation, to be sure that the visitor understands how we see CG and
what the treatment entails and has a chance to ask questions and to begin the process
of increasing a sense of connectedness to important people in the client’s life. After
welcoming the visitor and setting the agenda, the therapist asks the client and her
friend or family member to discuss their relationship. Then the therapist asks about
any observations the visitor might have about the client before and after the death.
The therapist summarizes what s/he learns and then shifts to provide a brief version
of information about CG and CGT in order for the client’s friend to understand how
we see the client’s grief and how we are going to try to help, including a
consideration of some ways the visitor might be helpful. The therapist summarizes
and thanks the visitor and then asks to meet alone with the client. In a brief follow-

CASE FORMULATION
Jane's Death
Vulnerabilities
Early attachment insecurity
Acute grief Loss of sense of self
Self-critical

Complications
Guilt, self-blaming thoughts and beliefs related to the loss
Preoccupation with anger toward the nurses, God, Jane, and herself
Avoidance of people and places that remind her of Jane

Natural adaptive processes

Strengths
Loving Aunt
Caregiver
Artistic
Integrated grief Diligent worker

Fig. 1 The CG formulation as it applies to Jane

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up meeting the therapist thanks the client for bringing this person and asks the client
how they thought the session went. The discuss this very briefly and then briefly
review GMD and aspirational goals work and make plans for the upcoming week.

Weekly plans Activities for the week include daily grief monitoring and continued
work on aspirational goals and making notes about things they want to mention
about the session with the visitor.

Core Revisiting Sequence: Sessions 4–9

The core revisiting sequence includes focused work on accepting the loss,
introduction of work with continuing bonds and continued work on finding a
satisfying ‘‘new normal.’’ Sharing information, self-observation and self-regulation
and rebuilding connection are continued throughout this phase as is aspirational
goals. Imaginal and situational revisiting and memories work are introduced. The
revisiting exercises are designed to bolster capacity to reflect on the death and to
help integrate this focal event into the past and future relationship with the deceased.
People with complicated grief, like the rest of us, need to come to terms with the
fact that all life ends with death, and in this sense, death is an integral part of life. As
such, unwanted as it is, death is as much to be honored as are the many human faults
we come to accept and even treasure in those we love.
When revisiting is successful, clients begin to find a way to think about the death
of their loved ones while continuing to live their own lives fully. However reflection
is never completed after a loved one’s death. We all grapple with the meaning of
death throughout our lives. As we do so, we naturally revisit and revise our
understanding of the death of our loved ones. The goal of CGT is to release this
natural process from the stranglehold of complicating thoughts, feelings, and
behaviors.
In summary, goals of the core revisiting sequence are to (1) Reduce behavioral
and experiential avoidance of reminders of the loss, (2) Decrease the emotional
impact of the story of the death and help the patient comprehend the painful reality,
(3) Reflect on and resolve troubling aspects of the death, (4) Continue work to
define and plan how to meet long-term aspirational goals and facilitate the
experience of genuine positive emotions, and (5) Encourage re-engagement in
ongoing daily life and relationships.

Session 4

This session begins the core revisiting sequence. The session begins with agenda
setting. The therapist encourages the client to reflect briefly on Session 3 and then
move to a review of the grief monitoring diary and acknowledgment of continued
goals work. Then the therapist shifts and introduces the imaginal revisiting exercise,
describing the rationale and providing a detailed description of the procedure. The
therapist describes the SUDS (Subjective Units of Distress) rating procedure, checks

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the client’s understanding of this as well as the rest of the procedure, and asks for
any questions. Then the therapist starts an audio recording, checks SUDS level and
invites the client to close her eyes and visualize herself at the time she first learned
of her loved one’s death. Continuing to visualize herself, she tells the story of what
happened next. The therapist asks for SUDS level about every 2 min, without any
further comments or discussion. After about 10 min the therapist stops the recording
and asks the client to open her eyes and report her SUDS level. The therapist invites
the client to reflect on the experience of telling this story. The therapist’s own
reflections are not included in the discussion at this point. After about 10 min the
therapist concludes this exercise by checking SUDS level and doing another
visualization exercise to put the story away. We ask the client to imagine that the
story she just told is on a videorecording. We ask her to visualize herself putting the
recorder into the machine, pushing the rewind button, listening to the tape rewind,
then stopping, ejecting and putting the cassette away in a safe place. The session
moves to a discussion of rewarding activities and aspirational goals work and
concludes with a brief therapist summary of the session, client feedback and
discussion of interval plans.

Weekly plans Activities for the week include continued daily grief monitoring,
aspirational goals and plans for listening to the recording of the revisiting exercise
followed by doing a rewarding activity.

Session 5

Session 5 goals are to (1) Review grief monitoring, (2) Continue imaginal revisiting,
(3) Introduce the situational revisiting list, (4) Discuss aspirational goals and (5)
Continue weekly activities. The session begins by setting the agenda followed by a
brief discussion of grief monitoring, a review of the client’s experience listening to
the imaginal revisiting tape, doing a second imaginal revisiting exercise, introducing
situational revisiting, discussing aspirational goals and planning for the upcoming
week. The therapist problem solves any difficulties with the imaginal revisiting
exercise and aspirational goals work in a way that feels safe and supportive.
The second revisiting exercise is a simple repetition of the first and often
illustrates how the story changes with repetition. Some things are emphasized,
fleshed out or clarified, while others are mentioned less. Strong emotions typically
lessen sometimes replaced by spikes in other places in the story. The period of
reflection may also be different as the client begins to notice and process different
aspects of the experience. While such change is common, it is not necessary for the
exercises to be effective.
In this session therapist re-introduces situational revisiting, repeating the
rationale explaining that the desire to avoid is understandable when a situation
triggers painful reminders that the deceased is gone. However, extensive avoidance
undermines the ability to come to terms with the death and its consequences and
restricts the possibilities for finding fulfillment in ongoing life. It is more difficult to
restore interest in other people and situations if a person is focused on not going to

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certain places, doing certain things or being with certain people. The therapist
explains that we start by listing people, places or situations the client is avoiding and
rating the degree to which each would trigger grief using a 0–100 scale. The Grief
Related Avoidance Questionnaire can be used to facilitate this discussion. The client
rates an example situation and the therapist discusses this. The session moves to a
discussion of aspirational goals followed by a summary of session highlights,
feedback from the client and discussion of weekly plans.

Weekly plans Activities for the week include continued daily grief monitoring,
aspirational goals, plans for listening to the recording of the week 5 revisiting
exercise followed by doing a rewarding activity and generating a situational
avoidance list.

Session 6–9

Goals for these sessions are to similar to session 5 and include, discussion of grief
monitoring, continued work on imaginal and situational revisiting, aspirational
goals and weekly plans. Memories work is also added beginning with session 6.
Specific work in any of these areas is dictated by the client’s interest and progress.
Imaginal revisiting continues to focus on the same story. If distress levels remain
high after 4 repetitions (by session 7) one of two possible modifications can be
helpful. If there is a particular place in the story that remains highly activating
(sometimes called a ‘‘hot spot’’) the client visualizes and describes just that moment
of the story and without opening her or his eyes, repeats this 3 or 4 times in rapid
succession. Doing the exercise in this way usually brings distress levels down pretty
dramatically and this can be disconcerting to people so this procedure should be
used judiciously. The other modification is used when distress levels are not coming
down between sessions, the client is not listening to the recording or is not reflecting
on the story. In this case, it can be helpful to do the imaginal revisiting exercise
procedure just focused on reflection or problem solving, omitting the visualization
and telling of the story. When this is done, the therapist needs to return to a full
revisiting exercise in a subsequent session.
Situational revisiting progresses during these sessions by reviewing the hierarchy
list and selecting an activity or situation that is feasible to do repeatedly and getting
the client’s agreement to do this multiple times during the week—ideally every day.
The activity chosen is one in which the distress level is in the range of 40–60. The
experience with situational revisiting is discussed in each session and a new exercise
is planned for the upcoming week.
Aspirational goals work ideally focuses on a specific long term project or activity
that is usually not achievable before the end of the treatment. The first few sessions
focus on helping the client decide on such a project. The focus then shifts to a
discussion of how the client will know they are making progress on this goal, how
committed they are to achieving it, what might stand in their way and who can help
them. Each week progress on the project is discussed and new plans made.

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Session 6 introduces a discussion of specific memories of the deceased using a

series of 5 memories worksheets that are introduced sequentially over sessions
6–10. These worksheets include stimulus questions to elicit warm and favorite
memories as well as memories of difficulties. The therapist works with these in the
session by simply reading through the responses and commenting briefly.

Weekly plans Activities for the weeks between sessions 6-10 include continued
daily grief monitoring, aspirational goals, plans for listening to the recording of
the revisiting exercise done in that session followed by doing a rewarding
activity, situational revisiting exercises and completing memories worksheets.
This is a significant time commitment on the part of the client that is intended to
be so, following the principle that interference in ongoing life is an important
motivator for adaptation.

Midcourse Review: Session 10

The third phase of CGT consists of taking reviewing progress to date and planning the
closing sequence. This usually means finishing up work that has been ongoing.
Sometimes though it makes sense to shift to work on a second loss or to shift to a current
interpersonal conflict or role transition using a brief IPT approach. For example, the
therapist might complete an interpersonal inventory and stage an interpersonal dispute.
Additional details about procedures used to address these interpersonal issues can be
found in Markowitz and Weissman (2004). The remainder of this paper focuses only on
the situation in which the closing sequence continues ongoing work.
To facilitate the midcourse review, the therapist returns to the formulation
developed in session 2, revises this if necessary and estimates progress in reaching
the overall objectives of resolving grief complications and facilitating adaptation.
The review is guided by the following questions: what are the complications
(thoughts, feelings or behavior) that have impeded adaptation? How well have these
been addressed so far? What has helped? What has changed? What work remains to
be done? How successful has work with aspirational goals been? What about
imaginal and situational revisiting? The answers to these questions are developed by
both a discussion with the client and a review of questionnaires.
Based on the review the therapist and client work together to decide how best to
spend the remaining sessions. The work usually includes a continued focus on both
goals and situational revisiting. In some cases imaginal revisiting is continued or
possibly just reflection on problems that remain in coming to terms with the loss. An
imaginal conversation is planned for the final phase. Grief monitoring and other
interval plans continue as before.

Weekly plans Activities planned at week 10 include continued daily grief

monitoring, aspirational goals, situational revisiting exercises and completing the
final memories worksheet.

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Closing Sequence: Sessions 11–16

Strategies and procedures for these sessions are more flexible than for earlier ones
with plans based upon results of the session 10 review. Each of the loss-focused
exercises from sessions 4–9 can be used in this phase. The choice of which to
employ is based on the decision about the focus of treatment. The closing sequence
includes Memories Form-5 in which the patient is asked to recall both positive and
negative memories. Session 11 and/or one of the later sessions also entails an
imaginal conversation with the deceased person. Under some circumstances, when
clinically indicated, the imaginal revisiting is continued into this phase and the
conversation is delayed. Another variation is to repeat the imaginal conversation in
more than one session in the closing sequences. Each session in the closing
sequence also includes a discussion of ending the treatment.

Sessions 11–15

Goals for the closing phase sessions are to (1) discuss the Grief Monitoring Diary,
(2) discuss thoughts and feelings about ending treatment, (3) do an imaginal
exercise as indicated (revisiting or imaginal conversation), (4) discuss situational
revisiting, (5) discuss aspirational goals work and (6) discuss weekly plans. In
addition the final memories worksheet, including positive and negative memories, is
reviewed in session 11.
The approach to discussion of termination in CGT follows an IPT role-transition
approach. The discussion centers around: (1) ways in which the therapy has been
supportive and helpful and feelings about losing this helpful support, (2) what has
been difficult, e.g. time required, travel and other inconveniences, ways that the
therapy has been difficult and time consuming, other things that may have been
distressing or problematic, (3) problems the person foresees in the future, including
managing difficult times and other problems that the patient may anticipate and (4)
opportunities and positive aspects of ending the treatment, including having more
time, having the opportunity to test new learning and develop a sense of confidence
in having assimilated something new that remains even when the meetings with the
therapist are over. The discussion follows the patient’s lead, but generally proceeds
from (1) and (2) above to (3) and (4). Positive aspects of the future without the
therapy is generally introduced at session 15 and discussed at session 16.
Calendar dates that trigger surges in grief intensity are difficult times for
bereaved people. Discussion of difficulties the patient foresees in upcoming months
and years includes anticipation and planning for difficult times. The patient is given
the Difficult Times handout in session 12 so that this can be discussed in sessions 13
and following.
The imaginal conversation is the final core CGT procedure. The therapist invites
the client to imagine that s/he is with her or his loved one not long after the death.
The client imagines that s/he knows the person has died, but that s/he can speak to
the deceased person and s/he can respond. The client tells or asks their deceased
loved one anything s/he wants. After speaking for about 5 min, the client pretends

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s/he is the loved one and answers. Then, s/he can become her or himself again and
respond to that answer. This ‘‘back and forth’’ conversation, conducted entirely by
the patient, should go on for about 15–20 min. Tell the client that just as with the
Revisiting exercise, you want her or him to try to visualize their loved one in the
room. You want them to imagine that they are really talking with them and imagine
how their loved one would really respond, even though this exercise is imaginary.
After completing the exercise the therapist invites the client to reflect on this
experience.
Each session in the closing sequence has a similar structure to the rest of the
treatment, beginning with setting an agenda and reviewing the grief monitoring
diary. There is generally some loss-focused activity followed by a restoration-
focused activity and ending with a summary of highlights, feedback and planning
for the upcoming week.

Session 16

The final session is a wrap up of the treatment that includes a summary of CGT
principles, goals and procedures, and discussion of how the client understood and
used these. There is a discussion of what has been accomplished and what remains,
as well as any thoughts and feelings about ending treatment and plans for the future.
Grief Monitoring and Goals work are continued in session 15 and reviewed for the
last time in session 16. Situational revisiting may be continued in session 15 and
reviewed for the last time in session 16.
The therapist reviews with the client what she has learned in the treatment and
notes progress on loss-related and restoration-related issues. The therapist also helps
the client identify and deal with any feelings, both positive and negative, about
ending the treatment and about the future. Plans for using and managing these
feelings are discussed. Plans are also discussed for continued work on personal
goals and on any other component of the treatment that is not fully completed.
Termination can sometimes evoke feelings of loss that can trigger grief. This
usually emerges on the Grief Monitoring diary. If grief intensity rises in the last few
sessions in relation to termination of the treatment, this becomes an opportunity to
illustrate how different loss experiences may trigger grief about her lost loved one.
Knowing that this is a natural process and that it does not indicate ‘‘unfinished
business’’ can be very helpful.
The final session is used as an opportunity for the therapist to summarize and
comment on her or his view of the treatment and the progress the client has made. It
is useful to summarize again the CGT model and the individual formulation and to
discuss how the client has or has not yet come to see things a little differently. It is
important to summarize the client’s strengths. Plan to give some examples of how
the client used her strengths in the treatment and also some concrete ways these
could be useful to her in the future. The session ends with a genuine statement of the
therapist’s positive feelings about working with the client, information about
availability in the future, and saying good-bye.

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Case Example

Jane was Grace’s older sister and her best friend, for as long as she could remember.
As a child, Jane was Grace’s idol. Her 5-years older sister always seemed like
everything Jane wanted to be. Their mother, repeatedly hospitalized for severe
depression, was not very available. Their paternal grandmother, a kind woman who
did not live with the family, did her best to fill in. However, as an immigrant who
did not speak English, she struggled to contain her energetic grandchildren. Though
only Jane married and had children of her own, Grace and Jane remained close, and
talked on the phone at least twice a day. Jane had done better in school and had a
more successful career, but Grace had better instincts as a mother. She was also
more artistic. Jane’s children loved their aunt. As a result, it was Grace who helped
Jane manage problems she had with her middle child. Grace was the confidant Jane
turned to when she learned that her husband was having an affair. They got through
that together, difficult though it was. Grace encouraged Jane to stay with her
husband Rob for the sake of the children. Then Jane learned that she was HIV
positive. Grace was panic-stricken. She said it felt like she couldn’t breathe—like
her life was slipping away.
Grace went with Jane to every doctor’s appointment and watched helplessly as
her beloved sister’s illness worsened. During her final hospitalization, Jane was
heavily medicated, and had episodes of confusion and paranoia. Grace, sleep
deprived and distraught herself, finally decided to follow the nurses’ advice and use
a day bed available to her in Jane’s room to get some sleep. When she awoke after
about 3 h, they were alone in the room and Jane was sleeping fitfully. Her breathing
seemed irregular. Grace thought something didn’t look right and decided to go find
a nurse. The nurses were in their morning report and could not be interrupted. Grace
waited, thinking to herself that she did not know how much more of this she could
take. When the nurses finally finished, one of them accompanied Grace into Jane’s
room. They found her very still. She had stopped breathing. Her eyes were open,
and Grace thought there was a look of fear on Jane’s face. Grace cried out, ‘‘NO’’
and collapsed on the chair by Jane’s bed. She covered her face and began to sob,
‘‘No’’ she said again, ‘‘No. No. No.’’ If Jane’s life had ended, Grace’s own life was
over too.
Four years later, her sister’s death remained as fresh to Grace as the week after it
happened. Her mother convinced her to seek help after Grace again refused to
celebrate Thanksgiving with the family. Whenever she thought about Jane’s death,
she would feel a profound sense of dread and remorse. She had not been at her
sister’s side during those last moments, and she feared Jane felt abandoned and
alone. Grace alternately blamed herself, the nurses, Jane or God for the fact that
Jane had died when Grace was out of the room. She still spent hours mulling over
the reasons she was not there and telling herself she had a valid excuse, only to find
herself besieged with angry self-criticism when she encountered a fresh reminder of
her sister. She was similarly preoccupied with trying to rationalize her anger toward
the others. She became convinced she would feel very differently about the death if
only she had held her beloved sister’s hand as she passed. No one could dissuade her

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of this idea and her friends and family, feeling helpless and frustrated, had stopped
trying. Grace functioned best at her job as the buyer in a children’s clothing store.
The only time she could distract herself from the longing she felt for Jane and the
insistent self-criticism was when she was working. Evenings and weekends she
spent isolated at home as it seemed that almost anywhere she went and anyone she
socialized with would remind her of Jane. Nothing dissuaded her from what she
perceived to be reality—that her life had ended with Jane’s. Grace felt badly about
letting her friends and family down, but she saw no way to be herself again. She
agreed to participate in CGT because her mother begged her to do so. She had little
hope that the treatment—or anything else—could possibly help.
Grace attended her first CGT session reluctantly. A friend had found our website
and suggested she might try it. She said she wanted her mother to ‘‘get off my case’’
and also said she knew she needed to get past this loss but in her heart she really felt
it was not possible unless the therapist could bring Jane back. The therapist did not
dispute this and said only that it was not surprising to her that Grace was feeling so
discouraged. She said that she (the therapist) nevertheless felt hopeful for Grace and
that one of her jobs was to carry hope for clients until they found that they could
take some of it on themselves. They spent the session getting to know one another,
primarily talking about Grace, her relationship with Jane and her intense grief. The
therapist also made sure she asked Grace to talk about herself and the things she
(and Jane) most admired. At the end of the session Grace had the thought that she
might have a new friend. Before she left, the therapist introduced the idea of
planning activities between the sessions and asked her to start keeping a grief
monitoring diary. The therapist also gave Grace a Handout explaining love, loss and
grief and asked Grace to consider inviting someone to come to session 3.
Grace had trouble completing the grief monitoring diary. She said she did not like
paying attention to grief and also found it hard to put a number on her grief. With an
edge in her voice she reminded the therapist that she had because she was paying
too much attention to her grief, not too little. However, she also said that she found
the Handout fascinating. The part about how grief was related love seemed new to
her and very interesting. She thought the description of complicated grief fit her
very well. She was not so sure about some of the plans for the treatment. The
therapist accepted Grace’s comments about the diary and said she understood that
doing this might seem a little counter-intuitive. She also said that its not unusual to
be uncomfortable with the diary but in her experience once people get used to doing
this monitoring they often find it very interesting and helpful. Grace agreed to keep
trying to do it. Then they talked about the CG model of acute and integrated grief
and the kinds of things that complicate grief. The therapist showed Grace a picture
of the model and identified her grief complications as ‘‘if only’’ thoughts—blaming
herself and others for how and when Jane died and her isolation and avoidance of
reminders of her loss. These issues were also making it much more difficult to
regulate the very natural feelings of yearning, sorrow and anxiety that kept surging
and making Grace feel so out of control. Then the therapist explained that the
treatment is designed to help activate and strengthen her own healing processes. She
told Grace about the core CGT procedures and discussed Grace’s reservations about
these. Then she asked to shift gears and invited Grace to do an exercise in which she

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imagined that the therapist could wave a magic wand and her grief was at a
manageable level and to think about what she would want for herself. Grace was
silent for a few minutes. Then she said she really wasn’t sure but when Jane was so
sick and Grace would sit with her while Jane slept, she had started to think about
making jewelry. In fact she had gone as far as buying some beads and silver. Now
she was thinking she would like to take some classes and start making jewelry. She
said her real dream would be to get good enough to sell it. The therapist said this
sounded very interesting. She asked Grace to think about how she would know if
she was making progress toward achieving this goal, how committed she was to this
idea, what could stand in her way and who could help her with it.
Grace’s mother Audrey came to the third session. She was a quiet person who
seemed sad and hesitant, but she also conveyed a feeling of warmth and there was
no question about her love for daughter. She talked openly about her own struggles
with depression when Grace and Jane were children and said that things have been
much better for her in the last 10 years. She expressed regret that she was not more
available to her daughters, but said that they had grown up to be lovely young
women in spite of that. She said she was very proud of them. She also said she was
very worried about Grace. Then she surprised them both by telling a story that
Grace had never heard. When Audrey was 25 and Jane was a baby, Audrey had a
best friend, Betsy, who was like a sister to her. Betsy had a brother who she loved
very much. Her brother had broken up with a girl friend and Betsy had arranged a
date with a girl she knew. Her brother died in a car accident on that date. Betsy was
devastated and could not stop blaming herself. She wouldn’t talk to Audrey about
anything else and eventually stopped coming over. Three years after her brother
died, Betsy took her own life. Grace was born shortly after this and Audrey became
severely depressed. Audrey and her doctor had talked about this when she was
hospitalized years ago and he had told her she needed to accept the fact that Betsy
was gone and move on. He said she had two beautiful children and she needed to
focus on them. Audrey had tried very hard to do this and so she never talked about
it. Now, with Jane’s death, it all came back. She said she thought she could
understand how Grace was feeling but she didn’t really know what to do to help.
She did not feel that her doctor helped her deal with Betsy’s death. She was thankful
that Grace was getting the help she needed and very grateful that she was invited to
come to the session and that she could finally tell Grace this story. Grace and her
mother hugged as her mother left the session. She was tearful as she reflected on the
session with the therapist and she thanked the therapist for encouraging her to invite
her mother to come.
Grace was 10 min late for session 4. She wasn’t sure if she was ready to talk
about Jane’s death. The therapist gently encouraged her to give this a try and Grace
agreed. Her distress level was at a 9 as she began and quickly escalated to ‘‘100 on a
scale of 1-10’’. She sobbed through much of the story but when she finished she said
she felt relieved. She had been very worried about this session. Her grief level was
still high, but she had a sense of accomplishment. She agreed to listen to the
recording at home. She was able to get herself to listen twice during the first week.
As planned, she and the therapist talked briefly after she listened the first time.
Grace repeated the revisiting exercise weekly for three more weeks and her distress

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levels fell noticeably. Without any direction from the therapist, she began to think
differently about her sister’s death. Her self-blaming thoughts diminished as did her
thoughts of blaming the medical staff. She began to think about how sad it was that
her sister became ill. For awhile she focused on her brother-in-law as the culprit but
eventually started to think that what was really sad was the AIDS epidemic and all
the beautiful people it had taken. After about 3 weeks she started reporting that her
sadness had a different quality. In some ways it was stronger but it was also
‘‘sweeter’’ and at the same time she felt lighter. She began to feel some hope for the
future.
Grace began to work on situational avoidance during the 5th session and she was
diligent about doing what she and the therapist planned each week. The first
exercise she did was to go shopping with Allyson a good friend who she had not
seen much lately. They planned a route that took them past a restaurant where Grace
and Jane often met for lunch. Over 3 weeks Allyson made herself available at least
3 days a week and Grace committed to walking past the restaurant the other days
either by herself or with someone else. At the end of this time, Allyson and Grace
had lunch together in this restaurant and Grace smiled broadly as she reported ‘‘I
actually enjoyed myself at lunch!’’ She also started doing a lot of things she had
been avoiding, including looking at pictures of Jane, going to the gym where they
would work out together and spending time with Jane’s family. She found each of
these things difficult at first but also found she could do them and she felt better
when she did. Her hope for the future continued to grow, especially because she was
also making progress in her jewelry making lessons. In session 12 she wore a pair of
earrings she had made and proudly showed them to the therapist.
Grace cried when she reviewed the memories worksheet with the therapist in
session 7. She said she missed Jane so much, but she continued to work with the
memories forms and by the 10 session, when she was asked about not-so-positive
memories, she was able to laugh as she recalled how Jane would sometimes trick or
bully her into doing something Jane wanted when they were little. Although she had
made good progress, Grace felt uneasy about having an imaginal conversation with
Jane when the therapist invited her to do this in session 11. Again, the therapist
simply encouraged her gently to do this, reiterating that this was definitely Grace’s
decision. Grace closed her eyes and visualized herself at Jane’s bedside right after
she died. She told Jane that she was so sorry that she had to suffer in this way and
she was especially sorry about not being with her at the moment she died. She
hesitated and then said there were so many things she was sorry about. She began
recollecting times she thought she had let Jane down. She hesitated again and said,
‘‘You know what really bothers me? It’s the way I encouraged you to stay with
Kevin even though we knew he was cheating on you. Why did I do that? Why didn’t
I realize I was putting your health at risk? If I had not encouraged you to stay, you
might have left him and never gotten AIDS.’’ Grace was crying now. The therapist
suggested she take Jane’s role and respond. Grace now spoke as Jane and said,
‘‘Gracie. Please don’t be so hard on yourself. You were always my very best friend
and really the person I loved most in the world, after my children. You were with
me constantly after I got sick. Sometimes I thought you must be a saint. I don’t
know how you did it.’’ She hesitated. ‘‘Gracie—you can’t blame yourself for my

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decision to stay with Kevin. For one thing, even if you did encourage me, it was still
my decision with whatever risks were involved. Not only that, I could always count
on you to help me think about my kids and that was so important. It was mostly
because of them that you wanted me to stay with Kevin.’’ She hesitated again.
‘‘There is one more thing. I know you had a hard time being around my family after
I died. That made me so sad. I really want you to be part of their lives. I always did
and not that I am not there, it is even more important. I really hope you will commit
to being there for them’’. ‘‘Grace switched back to her own role’’. She was crying
now. ‘‘Oh Jane. Of course I will do that. I am so sorry that I was a missing person
for so long. I want you to know that I am very committed to being there for your
children. I love them very much.’’ The therapist asked her to open her eyes and they
reflected on the exercise together.
Grace completed the treatment by finishing several more imaginal revisiting
exercises and completing her first jewelry making class. She had signed up for
another one and was making some plans to rent a studio with a woman she met in
the class. Her mother was very supportive of her jewelry and she had made her
mother a bracelet that she was wearing every day. She talked about how different
she was feeling. She said her relationship with her mother had changed completely
after the joint session when she learned about her mother’s terrible loss. They had
become closer than they ever were. Grace was also spending time every week with
her sister’s oldest daughter Lilly and had shared a lot of the CGT ideas and exercises
with Lilly. Jane’s birthday was coming up a few months after the last CGT session
and Grace and Lilly and Audrey were planning to spend the day together. They were
thinking of what they could do to honor Jane and take care of each other. Grace
ended the treatment feeling enthusiastic about her life and her future. She thanked
the therapist, saying she was so grateful. She said she never could have dreamed that
things could be so much better.

Summary and Conclusions

The efficacy of this treatment approach has been demonstrated in three clinical trials
as well as several studies using a closely related treatment (Boelen et al. 2007;
Wagner and Maercker 2007; Wagner et al. 2006; Asukai et al. 2011; Rosner et al.
2011; Acierno et al. 2012; Kersting et al. 2013; Barbosa et al. 2014; Bryant et al.
2014; Rosner et al. 2014; Supiano and Luptak 2014). In our first study CGT was
more effective than standard Interpersonal Psychotherapy in relieving CG
symptoms (Shear et al. 2005). In our second trial, we replicated these results in
older adults whose mean age was 66 (Shear et al. 2014). In our third trial, results of
which have been submitted for publication, CGT was again shown to be efficacious,
with an average response rate of 70 % across all studies.
CG is a prevalent condition that has been reported in bereaved individuals
worldwide. There is good evidence that it causes substantial distress and
impairment. It is important that clinicians learn to recognize and treat this
condition. Working with bereaved people can seem sad and hopeless so clinicians
sometimes shy away from work with grief and fear burnout. It may seem

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paradoxical, but therapists have often told us that learning CGT has been the most
rewarding experience of their career. Knowing how to administer a short-term
treatment that has a 70 % response rate is very gratifying and a powerful antidote to
burnout. This paper has outlined our approach. More detailed instructions for CGT
are available by contacting the Center for Complicated Grief www.
complicatedgrief.columbia.edu.

Compliance with Ethical Standards

Conflict of interest M. Katherine Shear reports research grants from the National Institute of Mental
Health (R01MH60783) and the Congressionally Directed Medical Research Programs of the Department
of Defense (W81XWH-15-2-0043). Dr. Shear also reports a contract from Guilford Press to write a book
on grief. Colleen Gribbin Bloom reports no conflicts of interest.

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