In most cases after the loss of a significant other, the bereaved experience Uncomplicated Grief (UG). In UG, grief wanes and the bereaved person experiences positive emotions alongside episodes of sadness. In complicated or traumatic grief, now diagnosed as Prolonged Grief Disorder (PGD), episodes of grief are frequent, prolonged and more intense. In uncomplicated grief (UG) there is a reduced longing for the deceased and gradual acceptance of the death, whereas with PGD a sense of intense yearning persists. In PGD, the bereaved can be engrossed in long periods of thinking about the deceased and pre-occupied with the death, which can trigger intrusive images of how the person died. In UG, life still holds meaning and purpose, therefore, the bereaved are able to resume activities and develop relationships. However, with PGD, avoidance and social withdrawal are more enduring. The most useful items to differentiate Complicated Grief from Uncomplicated Grief are: shock; intrusions about the deceased; resentment about the death; psychic numbing (being stunned or dazed by the loss); functional impairment; hostility; and avoidance of reminders of the death.

Prigerson HG, Maciejewski PK, Reynolds CF III, Bierhals AJ, Newsom JT, Fasiczka A, Frank E, Doman J, Miller M (1995). Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65–79.

Smith KV, Wild J, Ehlers A (2020a). The masking of mourning: Social disconnection after bereavement and its role in psychological distress. Clinical Psychological Science, 8, 464-476. doi:  10.1177/2167702620902748

Smith KV, Ehlers A (2021) Prolonged grief and posttraumatic stress disorder following the loss of a significant other: An investigation of cognitive and behavioural differences. PLoS ONE 16(4): e0248852. https://doi.org/10.1371/journal.pone.0248852

Grief is recognised as a normal human reaction to the death of a loved one and incorporates unpleasant, potentially distressing emotions, intrusive images, and physical sensations. Understandably, there has been reluctance to 'pathologise' grief responses and for most bereaved people any initial intense emotions reduce within weeks and months. However, a  proportion of bereaved relatives experience difficulties that persist rather than diminish over time ranging between ten per cent (Kersting et al., 2011) and 20 per cent (Shear et al., 2011) and many do not seek clinical help (Lichtenthal et al., 2011) despite significant social impairment.

The COVID-19 pandemic has put the subject of death centre stage as millions of people worldwide have been bereaved in extraordinary circumstances and psychological therapists have been asked to provide effective therapeutic responses for clients with enduring distressing grief reactions. Whilst there has been some disagreement about details of diagnostic criteria, both the ICD 11 and DSM5 now have a category for PGD.

In my clinical experience, there are enduring complex grief reactions that require therapeutic interventions. PGD is now accepted as a diagnostic category in both DSM5 and ICD 11 but a discussion continues as to whether all forms of traumatic and prolonged grief responses can be encapsulated within a single diagnostic category study (see Duffy and Wild in press).

Duffy M and Wild J (under review) Living with Loss: A cognitive approach to Prolonged Grief Disorder- incorporating complicated, enduring and traumatic grief

Kersting A, Brähler E, Glaesmer H, Wagner B (2011) Prevalence of complicated grief in a representative population-based sample. J Affect Disord. ;131(1-3):339-43. doi: 10.1016/j.jad.2010.11.032. Epub 2011 Jan 8. PMID: 21216470

Lichtenthal WG, Nilsson M, Kissane DW, Breitbart W, Kacel E, Jones EC, Prigerson HG (2011). Under-utilization of mental health services among bereaved caregivers with prolonged grief disorder Psychiatric Service 62, 1225–1229. doi: 10.1176/appi.ps.62.10.1225

Shear MK, McLaughlin KA, Ghesquiere A, Gruber MJ, Sampson NA, Kessler RC (2011). Complicated grief associated with Hurricane Katrina. Depression and Anxiety 28, 648–657. doi: 10.1002/da.20865

The concept of 'disenfranchised grief' (Doka, 2002) is relevant to this question whereby grief is not being openly acknowledged, socially validated or publicly observed in a usual and traditional manner such as with religious rituals, funerals and community-based activities. This concept can be relevant to bereavement complications in circumstances such as the recent COVID-19 pandemic during which many people died in extraordinary circumstances and grief could not be openly acknowledged or socially accepted. People died in hospital wards isolated from family members, attendance at funerals was restricted and there was an element of stigma attached to death by a new frightening disease. Rituals may be held at a later stage, for example at the time of an anniversary, to acknowledge the loss of the bereaved and recognise or celebrate the life of the deceased. Recent studies have demonstrated the importance of social withdrawal as a factor associated with PGD (see Smith & Ehlers, 2020) and the absence of such rituals can contribute to social isolation and withdrawal.

Doka, K (2002) Disenfranchised grief: new directions, challenges and strategies for practice. Champion III, Research Press   

Smith KV, Wild J, Ehlers A (2020). The masking of mourning: Social disconnection after bereavement and its role in psychological distress. Clinical Psychological Science, 8, 464-476. doi:  10.1177/2167702620902748

There is little evidence of benefits from 'grief work' in general to come to terms with the death of a loved one. A meta-analysis of 35 grief therapy studies found that treatments for grief had a limited and small effect relative to other forms of psychotherapy (Litterer, et al, 1999). Currier and colleague’s (2008) meta-analysis of grief therapy studies found that interventions had a small effect at post-treatment and no statistically significant benefit compared to control groups at follow-up.

Early models of grief derived from Freud’s theories (1963) proposed that grief was the necessary process of breaking attachment to a love object, 'the cost of commitment' (Parkes, 1972). Subsequent models were derived from Kubler-Ross’s (1969) observations of people living with a terminal illness, proposing that the bereaved had to adjust to the loss via stages of shock, denial, bargaining, depression and finally acceptance.

More recently, new models have emerged and tested empirically. Boelen and colleagues (2006) developed a CBT-based treatment for complicated grief which combines exposure and cognitive restructuring components similar to the core elements of the cognitive model for PTSD (Ehlers & Clark, 2000). Shear, and colleagues (2005) have designed a manualised Complicated Grief Therapy (CGT) integrating components of Cognitive Behavioral Therapy for PTSD with elements of interpersonal psychotherapy for depression. The evidence base for these CBT based models is developing and encouraging. Our group at Queens University Belfast and colleagues at Oxford University CADAT have been successfully applying the cognitive model of PTSD  (Ehlers & Clark, 2000) to guide our conceptualisation and treatment of Prolonged Grief Disorder (Wild, Duffy, Ehlers, under review).

Boelen, PA, van den Hout MA, van den Bout J (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13, 109 –128. http://dx.doi.org/10 .1111/j.1468-2850.2006.00013.x

Shear K, Frank E, Houck PR, Reynolds CF (2005). Treatment of complicated grief: a randomized controlled trial. Journal of the American Medical Association 293, 2601–2608.

Ehlers A, Clark DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38, 319–345.

Wild, J, Duffy M, Ehlers A, (under review) Moving forward with the loss of a loved one: Treating PTSD for traumatic bereavement with cognitive therapy

It is important that a therapist has an awareness of the relevant wider contextual (socio-political) factors in treating PGD arising from conflict, but the TF-CT model applied and protocol is similar. Assessment is important to discuss the impact of the loss and discover any additional meanings due to the nature of the death. In circumstances where the loved one has been killed by intentional acts of violence, anger can be prominent and strong.

In such cases, it is crucial that the therapist empathises with such anger, but recognises the negative effects of becoming entrapped in hatred and hostility that can deteriorate into bitterness and thoughts of vengeance. In some cases bereaved parents will initiate campaigns for justice which are important, but be aware that some bereaved relatives can dedicate their lives to such campaigns at the expense of caring for themselves or other surviving family members.

It is important for those bereaved to try to stay socially connected and try not to ruminate about the death of the loved one. Recent studies have demonstrated the importance of social withdrawal as a factor associated with PGD (see Smith & Ehlers, 2020) and there is an interesting link between the bereaved person’s appraisals and social withdrawal behaviours (eg I am a changed person; people will view me as different; I cannot cope without the deceased).

Rumination related to negative thoughts about life without their loved one as well as negative appraisals related to the memory of how the patient died keep the patient’s focus on loss. In response to the negative appraisals and sense of loss, the patient may engage in behaviours to feel less distressed. However, these behaviours, such as frequent visits to their loved one’s grave, or reducing contact with friends or disengaging from social activities, keep their attention on loss and maintains their distress. 

When working with appraisals linked to anger, psychoeducation is important (eg why certain types of cancer are misdiagnosed). Also consider the advantages and disadvantages of holding onto anger. It can be helpful for the patient to write an ‘anger letter’, which they do not send, to the person they are angry with clearly spelling out why they are angry and what they want the person whom they perceived to harm their loved one to know. When the patient’s loved one suffered in hospital or received poor care, they may decide to write a letter through the appropriate process to raise concerns and makes suggestions on how care could be improved.

As a therapist, it can be a delicate matter to provide advice on the pursuit of justice either via social campaigns or via the courts. However, such proceedings can complicate and prolong the grief process. We can ask patients to consider what difference legal proceedings will make to their actual loss and how much time and resource the legal proceedings require that may be diverted from other family members.

At present, the standard instrument for assessing CPTSD is the International Trauma Questionnaire (see Cloitre et al., ref below).

Trauma focused psychological treatments are recommended as first-line treatments for PTSD in NICE and international guidelines. However, a recent meta-analysis (Menton et al., 2020) concluded that there is limited evidence that trauma-focused treatments are effective for the emotional dysregulation and interpersonal problems in CPTSD. While many clinicians and researchers advocate a phased approach to treating CPTSD where the trauma-focused work is preceded by a period of 'stabilisation', there is limited empirical evidence that phased interventions are more effective or acceptable than standard trauma-focused interventions.

Our QUB group, in collaboration with colleagues at Oxford University, have just started a multi-site RCT to investigate whether a phased version of trauma-focused cognitive therapy for PTSD (TF-CT) that includes a self-compassion focused stabilisation phase, is superior to standard TF-CT in the treatment of CPTSD. We will be able to report on these results when the trial is complete.

Menton, H., Meader, N., Dale,H., Wright, K., Jones-Diette, J., Temple, M., ….Coventry, P. (2020). Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review. DOI: 10.3310/hta24XXX

Cloitre, M., Shevlin M., Brewin, C.R., Bisson, J.I., Roberts, N.P., Maercker, A., Karatzias, T., Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and Complex PTSD. Acta Psychiatrica Scandinavica. DOI: 10.1111/acps.12956

It is important to first be aware of the symptoms where PTSD and PGD overlap and where these disorders fundamentally differ. Common characteristics include: a sense of being stunned or shocked (by the trauma in PTSD and by loss in PGD); emotional numbing; intrusive memories and thoughts; avoidance of reminders; survivor’s guilt; feeling detached from others; and intense emotions with significant functional impairments. The primary emotions in PTSD are usually fear, anger, guilt or shame depending on the dominant appraisals, whereas in PGD the primary emotional response is usually intense sadness and yearning. Intrusions are common to both disorders but in PTSD are associated with the traumatic event and involve a sense of external threat or threat to the sense of self, whilst in PGD intrusions concern the deceased and predominantly involve a sense of loss.

It is important to differentiate between triggers for distressing traumatic intrusions of how the person died and triggers that induce loss-related memories in order to apply the most appropriate therapy techniques. The CT-PTSD model emphasises the important maintenance role of negative appraisals, unhelpful coping strategies, and characteristics of the trauma memory. We have found in our clinical practice with PGD that many of these strategies keep the patient’s attention focused on loss.

In my clinical experience, PTSD symptoms, such as hyper-vigilance, can be present in PGD especially amongst parents who lose a child in sudden traumatic circumstances (either accidental or violent traumas) and become hyper-vigilant in relation to protecting their surviving children. It is important to discover the specific appraisals linked with these behaviours which are usually within the theme of over-generalised and exaggerated threat. 

Smith KV, Ehlers A (2021) Prolonged grief and posttraumatic stress disorder following the loss of a significant other: An investigation of cognitive and behavioural differences. PLoS ONE 16(4): e0248852. https://doi.org/10.1371/journal.pone.0248852

Wild, Ehlers and Duffy (under review)