A New Treatment Program for the Grief That Won’t End

complicated grief image - Spectrum articleBy Simone M. Scully*

It was over a year ago when Sarah first heard a one-minute radio advertisement in the car that caught her attention. “Have you lost someone you love?” the woman’s voice in the ad asked. “Does the pain feel almost as strong today as it did in the beginning?

The ad went on to describe a syndrome that Sarah hadn’t known about, but felt described what was happening to her after losing several family members over the past ten years.

“It was just one after the other,” she said, “but when my Mom died, I think that’s kind of what threw me over the edge. I was very angry and sad. I pretty much stuck to myself and shut people out.”

By that evening, Sarah was calling to see if she was eligible to participate in the Columbia University research treatment project described in the ad.

Sarah, whose name is changed in this article to protect her privacy, suffered from a condition called complicated grief. This is a syndrome that Dr. M. Katherine Shear, the Marion E. Kenworthy Professor of Psychiatry in Social Work at CUSSW, has been researching and developing treatment for since 1996. Dr. Shear has had a life-long interest in the impact of separation from close attachments, which led her to work with Dr. Myron Hofer, now emeritus at Columbia University Medical School, in the 1970s.

“Part of what drew me in,” said Dr. Shear, “was that it became apparent that complicated grief grabs some people by their heels and pulls them under so they are drowning in their lives.” She estimates the syndrome afflicts seven percent of the bereaved population.

The typical grieving process

portrait of Dr. Shear - Spectrum article“I have never climbed Mt. Everest, but I sometimes think it would be easier than navigating the pathway through grief,” wrote Dr. Shear in an article for Dialogues in Clinical Neuroscience, published in June 2012. “Loss of a loved one is a natural, universally experienced life event and, at the same time, among life’s most challenging experiences.”

However, research shows that for the majority of people, the intensity of grief right after the death, referred to in the field as “acute grief,” becomes more manageable with time.

“It’s a transformation from acute grief to what we call integrated grief,” Shear explained. “The person stops dominating your mind and rests peacefully in your heart.”

Shear further noted that grief never really ends: “You’re never really going to stop missing someone whom you love who dies.” For most people, however, grief changes as they process their loss and start to re-engage in life.

When grief gets complicated

For the first time ever, complicated grief will be considered a formal diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5),to be released in May of this year, though some details—including its title—remain to be worked out.

Most researchers agree that complicated grief develops when something hinders the natural progression of grief. The term “complicated” applies to grief in the same way medical doctors speak of “complicated illness” or a “complicated wound.” Just as a wound can develop an infection, delaying healing, complicated grief blocks the natural grieving process.

The syndrome, wrote Dr. Shear in an article for Bereavement Care, “can be suffered for years, even decades, after a loved one dies.”

Dr. Natalia Skritskaya, a research coordinator and therapist for the Complicated Grief Program working with Dr. Shear, further explained: “If it’s been more than six months, or more than a year, and the [bereaved] still feels as if it happened yesterday, and the relief is missing, it’s complicated grief.”

Lee, another patient of Dr. Shear’s, who also requested to go by a different name, experienced the loss of four family members in the space of two years. Lee said, “Like everyone else, I thought there would be a grieving process and then it will be over, but it didn’t work out that way. It never ended. Things just seemed to be getting worse, and a lot of my friends, they tried to be helpful … but … they didn’t really understand. I didn’t really understand myself ... I lost myself.”

Commenting on Lee’s experience, Dr. Shear said: “Some people are so upset about the loss that they can’t bear to think about it. Their life comes to a standstill because they’re avoiding things and not allowing themselves to process it, problem solve and come up with how they can make peace with the situation.” Certain types of loss, such as the death of a child or a sudden, unexpected or violent death can increase the chances of developing complicated grief. People with a history of mood and anxiety disorders or of multiple traumas and losses are also more susceptible.

Targeted therapeutic treatment

complicated grief box - Spectrum articleDr. Shear’s treatment method consists of a structured, 16-session psychotherapy program that focuses on helping those suffering from complicated grief accept the finality of their loss and rebuild their lives.

One of the treatment procedures used in the sessions is “imaginal revisiting.” Under the therapist’s guidance, the patient tells the story of learning about the death and then engages in a period of self-observation and reflection. The story is also recorded, and the patient takes it home and listens to it once a day.

Imaginal revisiting helps the grieving person find a way to come to terms with the reality of the death. It also helps sufferers of complicated grief learn to do this in doses, by confronting the pain and then setting it aside.

In addition, patients spend five weeks keeping memory worksheets, exploring positive and negative memories of the loved one. They are also encouraged to do an exercise that involves imagining having a conversation with the deceased person after the death. “Imaginal conversation” techniques help patients resolve troubling issues and enhance their sense of connectedness to the departed loved one.

At the same time as these procedures are taking place, therapists try to get patients to focus on their own lives and futures through “personal goals and aspiration work.” A major focus of this restoration-oriented treatment is on identifying and working to achieve a meaningful personal goal. Lee, for example, rediscovered a love for writing.

Another exercise used in the sessions is “situational revisiting,” in which patients revisit situations they are avoiding because they evoke painful emotions about the loss. This procedure addresses not only the loss but also the need for a new focus. Patients reflect on the consequences of the loss while also trying to remove restrictions they have placed on their ongoing lives.

In the 2005 issue of the Journal of the American Medical Association, Dr. Shear reported that her Complicated Grief Treatment performed significantly better than a good supportive psychotherapy of the sort that someone with this condition might otherwise receive.

Official recognition as a University “center”

In fall 2012, Dr. Shear received the news that her program would be given the status of a Columbia University “center”. She said she appreciates the official recognition of the work she has been doing for years—consisting of developing and testing assessment and treatment tools for complicated grief with National Institute for Mental Health funding.

The focus of the new center, she added, is on educating the public, training health and mental health professionals, developing educational curricula, and supporting innovative research around the topic of complicated grief. She has already started conducting a series of training sessions for mental health professionals who are interested in understanding complicated grief as well as the principles used in her therapy.

So, do Dr. Shear’s patients feel like the treatment helped them? “I finally had hope and joy in my life again,” said Lee about life after the treatment. According to Dr. Shear, Lee’s reaction is typical. “Loss is forever and so is grief, but by the end of the program, most people say they have regained a sense of purpose in life and feel they can experience joy and satisfaction,” she said. “They also leave the program feeling more at peace with the death and with new ways of dealing with difficult times, like holidays or birthdays.”

* Simone M. Scully is currently enrolled in the Columbia School of Journalism (MS'13). Her article first appeared in the Winter 2013 issue of Spectrum, the magazine of the Columbia University School of Social Work.

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