Complicated Grief: Therapeutic Interventions

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Complicated Grief: Therapeutic Interventions

Introduction

Grief is a universal human experience encountered by many people at some point in their lives. It is a natural reaction to the loss of something meaningful (Harris & Winokuer, 2019). While some people can overcome grief relatively quickly on their own, others get stuck in ruminations for a long time. When individuals experience acute grief symptoms such as intense longing for the deceased, avoidance of reminders, and difficulty moving on with life for more than six months after the bereavement, they can be diagnosed with a prolonged grief disorder or complicated grief (Harris & Winokuer, 2019). This paper will compare two therapeutic interventions used for helping people with complicated grief: meaning reconstruction therapy and cognitive-behavioral therapy (CBT). While both interventions deal with cognitive dimensions of the grieving process, meaning reconstruction therapy deals with individuals making sense of loss, while CBT addresses clients negative thinking patterns preventing them from moving on with life.

Explanation of Interventions

Complicated grief interventions are based on theories explaining the grieving process. There are several theories of bereavement: the attachment theory, the dual-process model, the two-track model, the stage theory, the task theory, the continuing bonds theory, and the meaning reconstruction model (Harris & Winokuer, 2019; Nakajima, 2018). Attachment is a key concept in understanding the grieving process. Attachment bonds are formed with significant figures and do not depend on the quality of relationships (Harris & Winokuer, 2019). When losing a significant person, individuals respond to the loss according to the attachment pattern they formed with their parents in infancy (Harris & Winokuer, 2019). The attachment theory and other models of the grieving process view grief as a natural process rather than a pathological one. Although specific elements of various theories differ, a general understanding is that after a loss, a person needs time to accept the reality of death, process the pain, and restore normal functioning in the world without the deceased.

Meaning reconstruction therapy is focused on helping individuals to find meaning in the loss and the future life. This intervention is grounded on the idea that people try to find meaning in all events that constitute their lives (Neimeyer, 2019). However, when they lose a significant person, especially due to traumatic or premature death, their assumptions about life can be shuttered, forcing them to make sense of loss (Neimeyer, 2019). In the attempts to accept a new reality, individuals construct more meaningful life stories, and the aim of meaning reconstruction therapy is to help them in this process. This intervention assists people in finding a meaningful place for the death in their continuing self-narrative, reviewing the story of the relationships with the deceased, and establishing a nonphysical attachment bond with the deceased (Harris & Winokuer, 2019). It aims to address individuals ruminative counterfactual thinking about the self, the deceased, other people, and the circumstances of the loss event, which may lead to complicated grief (Neimeyer et al., 2021). Using narrative techniques, meaning reconstruction therapy produces positive psychological changes by helping people find significance in their loss.

CBT is a psychological intervention that is used for various mental health problems, including complicated grief. This intervention addresses individuals negative thinking patterns as it has been proven that negative beliefs about the self, life, and the future, as well as self-blame and catastrophic misinterpretations, play a significant role in complicated grief (Cesur-Soysal & Durak-Bat1gün, 2020). The CBT intervention can be divided into three general treatment stages leading the individual to the restoration of life functioning. The first stage is introductory, during which individuals share their experiences of the loss, develop motivation for treatment, and set goals (Boelen et al., 2021b; Rosner et al., 2019). The second stage is exposure and reinterpretation, involving gradual confrontation with avoided loss-related stimuli (objects and memories) and identifying and altering maladaptive cognitions (Boelen et al., 2021a; Rosner et al., 2019). The final stage is integration and transformation, during which individuals review the learned skills and gradually increase their involvement in usual life activities (Boelen et al., 2021a; Boelen et al., 2021b; Rosner et al., 2019). Although actual treatment steps may be more numerous and detailed, CBT commonly follows the general principle of progressing from goal setting to exposure and reinterpretation and further to transformation.

Comparative Analysis of the Two Interventions

CBT and meaning reconstruction theory are different in several ways. First, they are based on distinct models of the grieving process. CBT is grounded in the cognitive-behavioral model, according to which three processes maintain complicated grief (Boelen et al., 2021b). They include inadequate integration of the loss with prior knowledge, persistent negative thinking about the self, and anxious and depressive avoidance (Boelen et al., 2021b). In other words, grieving individuals maintain separation distress by failing to integrate the loss into their worldview, not believing in their ability to cope with the loss, tending to avoid reminders of the loss, and withdrawing from normal activities.

In contrast, meaning reconstruction therapy is based on the meaning reconstruction model of bereavement. According to this model, individuals engage in three processes for meaning reconstruction after a loss: sense-making, benefit-finding, and identity change (Tian & Solomon, 2020). It means that the bereaved try to make sense of loss, uncover its impact on their lives, and find life lessons and opportunities for personal growth in the loss (Barboza et al., 2021). In the case of complicated grief, these three processes are disrupted, undermining the persons ability to move on with his or her life. Thus, although CBT and meaning reconstruction therapy are based on different models, the similarity between these frameworks is that they explain complicated grief as a disruption in a normal grieving process. In the cognitive-behavioral model, grief becomes prolonged because of negative thinking patterns, while in the meaning reconstruction framework, it gets complicated because of a failure to make sense of loss.

Both interventions are focused on cognitive dimensions of the grieving process, but they emphasize different aspects of cognition. CBT is centered on addressing individuals dysfunctional thoughts and replacing them with adaptive ones, as well as turning patients painful memories into comforting ones (Rosner et al., 2019). In contrast, meaning reconstruction therapy focuses on the individuals inner narrative, or, more precisely, the disorganization of this narrative that occurs in complicated grief (Neimeyer et al., 2021). Thus, while CBT attempts to alter patients maladaptive cognitions, meaning reconstruction therapy aims to help individuals fit the loss into the story they tell themselves about their lives.

Since the two interventions view individuals cognitive processes differently, the specific treatment techniques they implement for grieving patients differ to a certain extent. CBT uses relaxation techniques to reduce stress and encourages patients to record their grieving thoughts daily to identify those of them that trigger complicated grief symptoms (Rosner et al., 2019). Further, individuals dysfunctional thoughts are reviewed for their usefulness and reality, and functional thoughts are developed instead (Rosner et al., 2019). At the end of CBT, patients may be asked to write down the content discussed during sessions, plans, and new role expectations (Rosner et al., 2019). In contrast, meaning reconstruction therapy uses narrative techniques addressing two dimensions of the clients attempts to integrate the loss into their lives: the event story of the death and the back story of the relationship with the deceased (Neimeyer, 2019). Specific techniques include restorative retelling, imaginal conversations, writing letters to the deceased, direct journaling, and participating in meaningful rituals connecting the client to the deceased (Barboza et al., 2021; Neimeyer, 2019). While the techniques of these two interventions differ, one common goal they try to achieve is establishing a continuing bond with the deceased.

Strengths and Limitations of the Interventions in Relation to Complicated Loss and Grief

As was mentioned, complicated grief is diagnosed when people experience acute grief symptoms more than six months after the loss. Although complicated grief can be seen as a deviation from a normal grieving process, Harris & Winokuer (2019) emphasize that counselors should not view prolonged grief as a pathology. Instead, clients difficulty integrating the loss into their lives means that they lack the necessary resources (safe space or support) to process the loss (Harris & Winokuer, 2019). Therefore, the counselors role is to provide individuals with these lacking resources to help them find meaning in the loss. Harris & Winokuer (2019) suggest that both CBT and meaning reconstruction therapy are viable treatment modalities for people with complicated grief. This section will explore the strengths and weaknesses of each of these interventions in relation to prolonged grief.

Strengths and Weaknesses of CBT

CBT is one of the most often mentioned treatments with regard to complicated grief. For example, Nakajima (2018) reports that CBT has been shown to effectively reduce complicated grief symptoms. Several studies found the exposure components of CBT to be particularly effective because they facilitated individuals ability to think about death and decreased avoidant thoughts and behaviors (Nakajima, 2018). However, exposure is not an inherent technique in CBT; for example, Nakajima (2018) cites a study that found CBT with exposure therapy to be more effective for complicated grief than CBT alone. Thus, when used for prolonged grief, the CBT intervention is modified to meet the specific needs of grieving individuals. The ability of CBT to incorporate techniques that adapt the therapy for this particular population can be seen as a strength of this intervention.

Another strength of CBT in relation to complicated grief is its applicability to different settings and populations. Evidence shows that it can be effective in individuals of different age groups. For example, Alahakoon (2018) reports that the CBT intervention with creative techniques, such as letter writing, drawing, and commemorating rituals, reduces complicated grief symptoms in bereaved children who have survived parental death. Likewise, Boelen et al. (2021b) conducted a randomized controlled trial to compare the effectiveness of CBT and supportive counseling and found that CBT was more effective in alleviating prolonged grief symptoms in bereaved children and adolescents. This is because CBT addresses individuals negative thinking and maladaptive coping and improves their problem-solving skills and engagement in pleasant activities (Boelen et al., 2021b). It is important to note that the CBT intervention in this study involved exposure techniques, amplifying the idea that CBT should be specifically adapted to complicated grief to be effective. Evidence shows that CBT helps reduce grief symptoms when it is conducted remotely through a telephone or videoconferencing (Boelen et al., 2021a). Thus, CBT has wide applicability in complicated grief, with its effectiveness established in many studies.

Although CBT has several strengths, the above review reveals that the major weakness of CBT is that this intervention alone may not have high effectiveness in treating complicated grief. For example, Elinger et al. (2021) report that even though CBT showed efficacy in improving complicated grief symptoms, its effect size was relatively small. Therefore, in order to produce significant positive results, CBT should be adapted to prolonged grief, particularly by including exposure components.

Strengths and Weaknesses of Meaning Reconstruction Therapy

In contrast to CBT, which is a widely applicable intervention, meaning reconstruction therapy was designed specifically for treating complicated grief, which can be regarded as its main strength. This intervention is particularly targeted at reconstructing the attachment bond with the deceased using techniques such as correspondence with the deceased or introducing the deceased (Steffen, 2018). In a study conducted by Elinger et al. (2021), meaning reconstruction therapy was performed using narrative reconstruction, allowing the patient to share the narrative of the loss, fill the gaps that emerged along this process, and elaborate on the personal meaning of the loss. This research showed that narrative reconstruction was effective for improving individuals prolonged grief symptoms right after the treatment and after a three-month follow-up (Elinger et al., 2021). Barboza et al. (2021) report that meaning reconstruction therapy can be used in couple therapy to facilitate shared meaning-making, which is important for bereavement resilience. Thus, meaning reconstruction therapy is a promising intervention in the field of complicated grief.

Yet, meaning reconstruction therapy appears to be a novel treatment; hence, no solid scientific evidence exists which would support the treatments effectiveness. As Elinger et al. (2021) point out, this intervention emerged as a response to the small effect size of CBT and patients failure to initiate or complete a full range of sessions in CBT therapy. However, the researchers acknowledge that meaning reconstruction therapy should be compared with other treatments in randomized controlled trials until eventual conclusions about its effectiveness can be made (Elinger et al., 2021). Hence, the major weakness of meaning reconstruction therapy is its relative novelty and, as a result, a lack of strong evidence showing the increased effectiveness of this intervention compared to other treatments for complicated grief.

Conclusion

To sum up, this paper analyzed two interventions CBT and meaning reconstruction therapy in relation to complicated grief. CBT aims to address individuals negative thinking and maladaptive coping, whereas meaning reconstruction therapy focuses on helping people make sense of loss. Regarding the effectiveness of the interventions, CBT appears to improve complicated grief symptoms when combined with exposure techniques. Meaning reconstruction therapy is shown to alleviate prolonged grief symptoms, but its effectiveness is yet to be tested in randomized controlled trials.

References

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