By Sue Morris MAPS, Director of Bereavement Services, Dana-Farber Cancer Institute, Boston, USA

Grief can be described as the intense emotional and physical reaction that an individual experiences following the death of a loved one. Not only is grief characterised by deep sadness but also by an intense yearning to be with that person again. It is well known that the death of a loved one is believed to be the most powerful stressor in everyday life, often causing significant distress to all those closely connected to the deceased (Holmes & Rahe, 1967). Bereaved individuals are more at risk of serious mental health problems such as depression and substance abuse, and increased risk of suicide (Prigerson & Jacobs, 2001; Stroebe, Schut, & Stroebe, 2007). Whilst bereavement is considered to be a normal human experience with the majority of individuals adapting over time to their loss, grief, however, remains an extremely painful period where adjustments can take months, if not years.

Psychologists can play an important role in helping the bereaved – the majority of whom will not have a DSM-IV diagnosis – adapt to their loss so that they can continue to live a meaningful life. The cognitive behaviour therapy (CBT) model provides a useful framework for clinicians as it allows us to understand bereaved people’s experiences and offer strategies to increase their sense of control. A CBT approach focuses on their thoughts and behaviour, not only about the death itself, but also about building a new life without the deceased. It can be easily tailored to help those clients with normal grief reactions where the intervention might have a psycho-educational and guidance focus, to a more structured, long-term intervention for those who are suffering from prolonged or complicated grief.

Understanding grief

No two people will experience the death of a loved one in the same way. How individuals express their pain depends upon a number of factors including their personality, the circumstances surrounding the death, and the way they view the world. One of the hardest things for people who are grieving is ‘not knowing’ what to expect, especially in the first few months. Often they question whether their experience is ‘normal’ and wonder whether they are going crazy. Part of the role of the psychologist is to educate bereaved people about what they might experience following the death in an attempt to increase their sense of control and facilitate their adaptation.

Loss, change and control

Loss, change and control are three of the major psychological components of grief. When somebody dies we naturally focus on ‘who’ died. But with any death comes the loss of so many other things. These other losses can range from practical roles such as the financial advisor or social director, to the person who represented the hopes and dreams for the future. Helping bereaved people identify what they have lost is an important step, as each loss needs to be addressed as a part of the grieving process. Change is an inevitable consequence of loss, and how much change individuals have to navigate tends to correlate with how much their lives overlapped with their loved one. Learning to adapt to these changes takes time and effort as it requires the bereaved to try new things. Finally, the concept of control plays a central role in the cognitive interpretation of grief. When somebody dies the bereaved have little or no control over the circumstances surrounding the death. They can feel overwhelmed by their grief and unsure about what to do to help themselves at a time when they feel especially vulnerable and alone.

Expectations

How someone thinks about life and death has a significant impact on how he or she will grieve. Most people expect that children will outlive their parents and that the majority of us will live long and healthy lives. When someone dies suddenly or prematurely many of these basic assumptions about life are challenged. Similarly, the diagnosis of a terminal illness and the subsequent death can also challenge a person’s belief about the world, often resulting in a discrepancy between what the bereaved expected and what actually happened. The greater the discrepancy, the more difficult it can be to adapt to the death of a loved one. This is one reason why the death of a child is considered to be one of the greatest losses as it challenges our beliefs about life and death and the way we think things ‘should’ be.

Expectations also play a significant role in beliefs about progress. It is not uncommon to hear the bereaved express comments such as, ‘It’s been three months, I thought I’d be better by now’. Such comments reflect the ‘fix-it’ mentality of our society. We want things done immediately and we tend to have little patience. It’s no surprise then that people, including those who are grieving, believe that grief should be something they can ‘get over quickly’ so they can ‘return to normal’, in much the same way as they’d recover from an infection. The problem is that this view of grief is incorrect. Grief is not an illness with a prescribed cure – it’s a normal and expected response to the death of a loved one. It is a highly individualised process that involves many ups and downs.

The wave-like pattern of grief

The experience of grief is best described as following a wave-like pattern which provides a useful framework in helping the bereaved understand their experience and, in turn, increase their sense of control (Morris, 2008). Most people report that the intensity and frequency of waves lessens over time even though ‘trigger waves’, which are usually accompanied by heightened emotions, can occur at any time, even years later. Triggers can include anything from hearing a song on the radio to seeing someone who resembles the deceased person. Some trigger waves come out of the blue and others are anticipated, such as a significant date. It is important to emphasise that trigger waves are normal and are not a sign that they are getting worse. In normal grief, the intense symptoms subside slowly but usually cause little impairment to functioning by six months following the death (Maciejewski, Zhang, Block, & Prigerson, 2007).

CBT for grief

The goal of CBT is to help the bereaved reconcile the death of their loved one, which involves giving them permission to grieve whilst also guiding and supporting them as they build a new life for themselves. Most bereaved individuals who present for help need to:

  • Be able to tell their story over and over
  • Express their thoughts and feelings repeatedly
  • Attempt to make sense of what has happened
  • Build a new life for themselves without the deceased.

Many of the CBT strategies that are used in the treatment of anxiety disorders and depression, such as graded exposure to avoided or feared situations, increasing pleasant events and challenging unhelpful thoughts, can be modified for working with bereaved people (Kavanagh, 1990). Strategies which focus on increasing the sense of control and wellbeing can help facilitate adjustment (see boxed information).

CBT is an effective model for working with bereaved people because it provides a framework to understand their experience, identify barriers that they may be facing, and to develop strategies to increase their sense of control. It can easily be modified for short or long-term therapy and also has great potential for group work.

The author can be contacted at sueemorris@msn.com

CBT STRATEGIES TO HELP THE BEREAVED

(Morris, 2008)

  • Establish a simple routine
    • Regular meal and bed times
  • Increase pleasant events
  • Promote self-care activities
    • Regular medical check-ups
    • Daily exercise
    • Limited alcohol intake
  • Provide information about grief and what to expect
    • Grief is unique and follows a wave-like pattern
    • Grief is not an illness with a prescribed cure
    • Children benefit from being included and learning that grief is a normal response to loss
  • Compartmentalise worries
    • List the things that are worrying
    • Create a ‘to-do’ list, prioritise and tick off items as they are completed
    • Use different coloured folders for the paperwork that needs to be finalised
  • Prepare to face new or difficult situations
    • Graded exposure to situations that are difficult or avoided
    • Plan for the ‘firsts’ such as the first anniversary of the death – How do you want it to be acknowledged? Who do you want to share it with?
    • Adopt a ‘trial and error’ approach; be prepared to try things more than once
  • Challenge unhelpful thinking
    • Encourage identification of thoughts leading to feelings of guilt and anger
    • Gently ask the following questions – What would your loved one tell you to do if they were here now? What are the alternatives to what you thought? Where is the evidence for what you thought?
  • Provide a structured decision-making framework to deal with difficult decisions e.g., When to sort through belongings? Whether to take off the wedding ring? Whether to move or not?
    • Base decisions on evidence, not emotions
    • Avoid making major, irreversible decisions for 12 months
      to prevent decisions being based on emotion
    • Identify the problem and possible solutions
    • List the positives and negatives for each potential solution
    • Determine the consequences for each solution – can they be lived with?

References

  • Holmes, T.H., & Rahe, R.H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213-218.
  • Kavanagh, D.J. (1990). Towards a cognitive-behavioural intervention for adult grief reactions. British Journal of Psychiatry, 157, 373-383.
  • Maciejewski, P.K., Zhang, B., Block, S. & Prigerson, H.G. (2007). An empirical examination of the stage theory of grief. Journal of the American Medical Association, 297(7), 716-723.
  • Morris, S.E. (2008). Overcoming grief: A self-help guide using cognitive behavioural techniques. London: Constable and Robinson.
  • Prigerson, H.G., & Jacobs, S.C. (2001). Caring for bereaved patients – all the Doctors just suddenly go. Journal of the American Medical Association, 286(11), 1369-1376.
  • Stroebe, M., Schut, H., & Stroebe, W. (2007).Health outcomes of bereavement. The Lancet, 370, 1960-73.