CBT for Grief: Clearing Cognitive Obstacles to Healing from Loss

Abstract

There is tremendous variability in people’s ability to cope with, and adjust to, the death of someone close to them. One of the factors identified as significant in this regard is the constellation of beliefs that includes a mourner’s thoughts about the circumstances of the death, their feelings about the person who died, their reflections on the relationship with that person, and their assessment of their own ability to survive the loss. This paper considers the role of cognition in adaptation to loss, and demonstrates how maladaptive cognitions concerning the loss, the manner of death or the relationship with the deceased can interfere with adaptation and lead to complications in grief. Case examples illustrate the use of CBT with bereaved clients and the benefits of this approach as part of an overall strategy for helping grieving clients. The effectiveness of CBT with bereaved individuals is enhanced when clients understand the rationale of the treatment and are committed to carrying out the tasks specified in their treatment plan. The article presents a simple model for promoting client involvement and compliance.

Full text

1 23
Journal of Rational-Emotive &
Cognitive-Behavior Therapy
ISSN 0894-9085
J Rat-Emo Cognitive-Behav Ther
DOI 10.1007/s10942-016-0241-3
CBT for Grief: Clearing Cognitive Obstacles
to Healing from Loss
Phyllis Kosminsky

1 23
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CBT for Grief: Clearing Cognitive Obstacles to Healing
from Loss
Phyllis Kosminsky
1
Springer Science+Business Media New York 2016
Abstract There is tremendous variability in people’s ability to cope with, and
adjust to, the death of someone close to them. One of the factors identified as
significant in this regard is the constellation of beliefs that includes a mourner’s
thoughts about the circumstances of the death, their feelings about the person who
died, their reflections on the relationship with that person, and their assessment of
their own ability to survive the loss. This paper considers the role of cognition in
adaptation to loss, and demonstrates how maladaptive cognitions concerning the
loss, the manner of death or the relationship with the deceased can interfere with
adaptation and lead to complications in grief. Case examples illustrate the use of
CBT with bereaved clients and the benefits of this approach as part of an overall
strategy for helping grieving clients. The effectiveness of CBT with bereaved
individuals is enhanced when clients understand the rationale of the treatment and
are committed to carrying out the tasks specified in their treatment plan. The article
presents a simple model for promoting client involvement and compliance.
Keywords CBT for grief Grief therapy Prolonged grief Traumatic grief
The CBT Framework and Its Application to Grief Therapy
‘‘The death of a beloved is an amputation…At present I am learning to get
about on crutches. Perhaps I shall presently be given a wooden leg. But I shall
never be a biped again’’ C.S. Lewis
&Phyllis Kosminsky
pkosminsky@gmail.com
1
Center for Hope/Family Centers, Darie
´n, CT, USA
123
J Rat-Emo Cognitive-Behav Ther
DOI 10.1007/s10942-016-0241-3
Author's personal copy

‘‘We might expect if the death is sudden to feel shock. We do not expect this
shock to be obliterative, dislocating to both body and mind. We might expect
that we will be prostrate, inconsolable, crazy with loss. We do not expect to be
literally crazy, cool customers who believe their husband is about to return and
need his shoes’’ Joan Didion
At its most profound and painful, grief is a rogue wave of despair, yearning, and
desire for reunion. The rational mind is little more than a bit player in the drama of
such extravagant emotion. This is the kind of grief we find represented in literature:
the high point of the wave, the pinnacle of fear, helplessness and suffering. In
contrast, the lived experience of grief is ongoing; the wave rises and falls from one
day, and even one moment, to the next. Much of our work with the bereaved is
about helping them ride the wave of their grief and doing what we can to guide them
in their journey toward a more tranquil shore.
Some people, of course, have more difficulty with the journey than others. We
know that there is tremendous variability in people’s ability to cope with, and adjust
to, the death of someone close to them. One of the factors identified as significant in
this regard is the constellation of beliefs that includes a mourner’s thoughts about
the person who died, their reflections on the relationship with that person, and their
assessment of their own ability to survive, in a practical or even literal sense,
without the deceased. The connection between what people think, what they feel,
and how they manage their emotional response to stressful life events, is at the heart
of cognitive behavioral therapy, and an organizing principle of its use in grief
therapy.
Malkinson (1996,2007) has described the fundamentals of a cognitive behavioral
approach to grief therapy, an approach that draws on the CBT-REBT model of
Albert Ellis, with whom she worked closely for 32 years. Ellis proposed that
emotional problems are the product of an interaction between environmental,
cognitive and behavioral influences, with cognition being central to this process
(Ellis and Harper 1975). Applying this model to bereavement (‘‘The ABC of
Rational Response to Loss’’, Malkinson 2012), Malkinson proposes that adaptive
grief is ‘‘…a healthy process of experiencing the pain of one’s loss, which includes
ways of thinking and emoting that help the bereaved person organize his or her
disrupted belief system into a form of healthy acceptance’’ (Malkinson 2012,
p. 129).
With many bereaved clients, the most straightforward approach to differentiating
between helpful and non-helpful cognitions is to ask, ‘‘Does this way of thinking
(about the death, or your life now and in the future) make you feel better or worse?
Does it give you more energy to carry on with your life or does it drain you of
energy and hope?’’ In the following example, a client of the author struggles with
self-defeating thoughts that complicate her grief and amplify the pain she feels over
losing her husband.
A widow in her late sixties whose husband accidentally choked to death, and
who found his body several hours later, declares that her life is over. She has
withdrawn from friends and from her children and grandchildren. She blames
herself for not being present when her husband died and continually revisits
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the memory of finding him and trying to revive him. Recalling all the times
that she ‘‘could have made him happy but didn’t’’, she is overwhelmed with
regret for not having been a more loving and attentive partner.
This case illustrates another of Malkinson’s points regarding the CBT model, that
being the need to identify and address negative and intrusive cognitions in instances
of traumatic loss. Trauma disrupts cognitive processing and survivors of traumatic
loss are especially prone to fragmentation of memories, exaggerated beliefs
regarding their responsibility for the death, and sustained levels of physiological
hyperarousal (Parkes and Prigerson 2010). Thus, the use of cognitive behavioral
approaches to treatment is most likely to be indicated in cases where the death is
sudden and unexpected (Malkinson 2012).
Bereavement as a Meaning Making Process
The need to understand and make sense of experience has long been regarded as a
fundamental feature of human existence (Frankl 2006; Suddendorf 2013). Meaning
making is a life long process, but one that assumes particular importance in the
wake of profound change, tragedy and loss. In this view, represented by the
constructivist tradition (Neimeyer and Mahoney 1996) the direct impact of life
altering events is amplified by the loss of meaning that accompanies them, an effect
that has been characterized as the loss of the assumptive world (Kauffman 2002).
The constructivist view of bereavement is most fully represented in the work of
Neimeyer, who conceptualizes bereavement as a process of meaning reconstruction
(Neimeyer and Mahoney 1996; Neimeyer 2001) and whose research has demon-
strated the important role of meaning making in adaptation to loss (Neimeyer and
Sands 2011).
Application of CBT to Address Cognitions that Impede Healing
In this section we will discuss problems in bereavement that are amplified and
sustained by cognitive processes, and which are thus potential targets for CBT and
related interventions. Many of these problems involve rumination, thinking
repetitively and recurrently about the causes and consequences of one’s negative
emotions and/or negative life-events (Nolen-Hoeksema 2001). In contrast to
meaning making, rumination, which often involves negative attributions that fuel
guilt, anger, and other painful emotions, hinders the resolution of grief (Stroebe and
Schut 1991; Watkins and Moulds 2013). In cases where the bereaved’s relationship
with the deceased was markedly dependent, fear about the not being able to survive
without them also tends to be a repetitive and self defeating theme in their thinking
(Kosminsky and Jordan 2016). Rumination is also associated with a desire to avoid
confronting the reality of the death or the circumstances in which the death
occurred, or other factors related to the nature of the death, including trauma,
absence of a body, or insufficient information about how the death occurred (Parkes
and Prigerson 2010).
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In their review of evidence concerning the role of rumination in problematic
grief, Watkins and Moulds (2013) note that what they refer to as repetitive thought
(RT), is a key part of the process by which we organize and integrate knowledge and
experience, including the experience of loss, and is thus evident in both normal and
pathological grief. What differentiates RT in problematic grief is not only the
content of the bereaved’s thinking (negative vs. positive), but the way in which they
engage in RT, specifically, whether their thinking about the loss is abstract or
concrete. As it relates to thinking about the sudden death of a loved one, abstract
thinking involves a focus on existential questions (‘‘Why did this happen to me?’’)
and global negative self evaluations (‘‘I am weak’’) whereas processing at a concrete
level would focus on the loved one’s last days, memories of their life, and plans for
the future. Abstract processing creates a range of problems in bereavement,
insulating the griever from the specific context of the loss, serving as a form of
avoidance, and providing limited guidance to action and problem solving (Watkins
and Moulds 2013). Based on this analysis, the authors propose that helping clients
with maladaptive rumination about their loss to engage in more concrete thinking
may be a useful adjunct to their therapy.
This recommendation accords with Malkinson’s discussion of a CBT based
treatment strategy used with a bereaved client whose husband had died of a brain
hemorrhage 10 months earlier (Malkinson 2012). The client was unable to get past
the kind of unanswerable questions that are such a source of emotional torture for
people faced with sudden loss. Malkinson comments:
‘‘Paradoxically (in these cases) the bereaved is engaged in a search for an
answer, but the repetitiveness forms a continuous cognitive loop that blocks
the solution and increases the distress…To help (this client) experience an
adaptive grief process…a dialogue with repetitive thoughts was applied.
Creating a dialogue with the ‘‘why’’ question is a way of increasing cognitive
control over an inner sense of not having one’’ (Malkinson 2012,
pp. 133–134).
Malkinson also emphasizes the value of homework assignments as part of a CBT
approach to work with the bereaved. Homework assignments can serve a variety of
purposes, but are particularly suited to encouraging clients to take responsibility for
various activities in their lives, to reduce anxiety, renew interpersonal relationships,
and facilitate a balanced relationship with the deceased (Malkinson 2012). In the
case of the client just described, Malkinson used homework assignments to help the
client work through her fear of visiting her husband’s grave. Part of this strategy
also involved teaching the client how to manage her feelings more effectively, so
that she would not be so afraid of being overwhelmed by them. Here again, this
approach is in accord with Watkins and Moulds’ observations concerning the
advantages of concrete as opposed to abstract thinking in facilitating adaptive
grieving (Watkins and Moulds 2013).
In the following section we will illustrate the contribution of rumination to
problematic grief in two clients whose repetitive thinking has trapped them in an
unproductive spiral of cognitive confusion and emotional pain.
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Case Examples
Margaret
It was Margaret, a 62 years old woman whose mother had just died, who introduced
the author to the phrase ‘‘coulda, woulda, shoulda’’. Week after week, it was the
refrain she would return to after posing a stream of questions about the
circumstances of her mother’s death and lamenting about all the ways in which it
might have been prevented. ‘‘Why did my brother let her have a cigarette when she
was in bed? Why did the doctor give her all that medication when he knew she was
addicted to painkillers? Why didn’t I pay more attention to what was going on with
her care?’’
The therapist reminded Margaret of her tendency to get stuck on the ‘‘coulda,
woulda, shoulda’’ track when she returned to treatment 6 years later, after the death
of her younger brother. Again, the circumstances of the death were such that
Margaret had many regrets and many unanswered questions. Margaret’s brother was
nearing the end of an 8 years prison sentence when he suffered a stroke. Margaret
was returning from a trip, and was planning to stop on her return to visit her brother.
She knew he had been having medical problems, but when she asked him about
them, he only replied that he would take care of himself ‘‘when I get out’’. When
Margaret arrived at the prison she was told that her brother was on a ventilator.
After sitting with him for several hours, and being told that his condition was stable,
Margaret went home to get some sleep. A few hours later she received a call telling
her that her brother had died.
Within a few weeks, when Margaret’s narrative began to spiral into the kind of
‘‘coulda, woulda, shoulda’’ thinking that had gotten her stuck in the past, the
therapist suggested that they try something new, something different than what they
had done when her mother died.
Margaret This is torture. I ask myself these questions a million times a day. I
can’t shut it off.
Therapist Right. You keep looking for answers. But you have no answers, so you
just keep asking the questions.
Margaret It never stops.
Therapist Right. So here’s an idea. What if you had answers? What if instead of
repeating these questions over and over, you try to answer them. The answers
might not be answers you like. But if you could answer the questions, it might
shorten the amount of time you spend thinking about and struggling with the
questions. Does that make sense?
(Margaret nodded slowly. ‘‘Yeah…I think I see what you’re saying.’’)
Therapist Why don’t you start by talking a little about his life, whatever you
remember.
Margaret recalled details of her childhood, some of them already familiar to the
therapist her parents’ drinking, their fights, the physical and emotional abuse.
Margaret escaped into what turned out to be a bad marriage. Her brother,
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meanwhile, started getting into trouble, first on a small, and then a larger scale,
and was in and out of prison for much of his adult life.
Margaret Why did he have to spend so much time in prison? Why couldn’t he
have had more of a life on the outside?
Therapist (Gives Margaret a ‘‘what do you think?’’ look).
Margaret To start with, I guess he started doing drugs, because he hated his life.
Hated being at home.
Therapist Uh huh.
Margaret And he needed money for the drugs.
Therapist Uh huh.
Margaret But why couldn’t he come to me for money? Instead of breaking the
law? Why couldn’t he come to me?
Therapist Well, I don’t know. But from what you’ve told me, he loved you a lot.
And you loved him a lot, and he knew that, and it was really important to him.
Your love.
Margaret (Tearful) Maybe he didn’t want to tell me because he knew that I’d be
after him to stop doing drugs.
Therapist That makes sense.
Margaret And maybe he didn’t want me to think about him that way. He didn’t
want me to think that he was a bad person.
Therapist You know, that really feels important to me, what you just said.
Because you were his big sister, and your love was so important to him, and he
couldn’t risk losing it. And he never did lose it, did he?
Margaret (Tearful) No, he never did.
After some further discussion the therapist helped Margaret review her questions
and answers and write them down. The therapist encouraged Margaret to look at this
list and to remind herself of the answers she had come up with whenever the
questions arose. After this, Margaret and the therapist talked about the fact that not
every question has an answer. Sometimes, they agreed, the only way to answer a
question is to acknowledge that it has no answer, and that this is the answer.
The following week Margaret continued this process, focusing on the lack of
attention that prison staff had paid to her brother’s serious medical problems. After
her brother’s death Margaret had written to his cell mate, and he had told her that
her brother had not wanted to go to the infirmary or the hospital: ‘‘All he wanted
was to be in his cell’’. This disclosure provoked a new stream of questions.
Margaret Why didn’t he tell me he was having these problems, how serious they
were?
Therapist What would have happened if he had done that?
Margaret I would have made him go to the doctor! I would have made him go to
the hospital!
Therapist And? Is that what he wanted?
Margaret No way! He didn’t trust the doctors in the prison. He didn’t trust the
hospital. He was convinced that if he let them take care of him he’d only get
worse. And who knows, maybe he was right.
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Therapist So if he had told you, there would have been an argument.
Margaret You bet.
Therapist And he didn’t want to argue with you.
Margaret No, that’s the last thing he wanted.
Therapist What was the first thing, the most important thing?
Margaret Just to know that I loved him, that I would always love him, no matter
what.
Therapist And he always knew that. He always had that. You always made sure
he knew you loved him and always would.
Margaret continued to write to her brother’s cellmate. It emerged that this man,
quite a bit younger than her brother, had been his friend and in some ways, his
surrogate son. Margaret asked him to tell her ‘‘only good, positive stories’’ about her
brother, and he did. These stories cast a bit of light on what Margaret had imagined
as an unrelentingly sad and lonely end to her brother’s life.
‘‘He was an artist, my brother,’’ Margaret told the therapist. ‘‘He painted a
picture of my husband that I have in my living room. And he collected things.
He loved flea markets. He would find stuff…a clock that I have; pieces of
pottery, all kinds of stuff. He had a great eye.’’
She paused. ‘‘My brother had a lot of pain in his life. And now that pain is
gone.’’
Margaret’s is not a happy story, and it does not have a happy ending. But in the
absence of a happy ending, there can still be a measure of relief. Being able to
articulate a response to the questions that had plagued her seemed to free Margaret’s
mind a bit and allow her to focus on positive memories of her brother, including
memories of all she had done and tried to do for him. One day she brought in a page
of quotes she had collected, including one from the film ‘‘A River Runs Through
It’’:
‘‘Each one of us will at one time or another in our lives look upon a loved one
who is in need and ask the same question. We are willing to help, Lord, but
what, if anything, is needed? For it is true, we can seldom help those closest to
us. Either we don’t know what part of ourselves to give, or, more often than
not, the part we have to give is not wanted. And so it is those we live with and
should know who elude us. But we can still love them–we can love them
completely without complete understanding.’’
‘‘That last line is the one that really gets me’’, Margaret said, tears in her eyes.
‘‘It’s a hard truth. But it’s a truth that helps me somehow. I can love him completely,
even though I didn’t, and still don’t, understand everything he did or why he died. I
gave everything I could to my brother. What more could I have given? We don’t
know what to give. We can only give what we know how to give. The other person
is not going to tell you what they really need, because they may not know
themselves.’’
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Although she was still occasionally visited by thoughts of her brother’s
incarceration or the circumstances of his death, Margaret took comfort in the
positive memories she had of his life and of their relationship. She knew she had
done everything she could do for her brother, and more.
Of course, not everyone has positive recollections of their relationship with
someone who has died, or believes that they did all they could have done for that
person. In these cases, guilt and regret amplify the pain of grief. This was true for
the client described next, a widow who believed that her failure to care for and
about her husband while he was alive was irrefutable proof that she was incapable of
truly loving another person.
Beth
Beth sought treatment a year after her husband’s death, having taken this step
mostly to assuage family and friends who insisted that she needed help. In the initial
consultation with the clinician, Beth described finding her husband at home some
hours after he had died. Adam was recovering from surgery and had been taking
heavy dose of painkillers. While Beth was away for the night caring for her mother,
Adam had apparently choked while drinking a cup of coffee. Since his death Beth
had been confining herself to only a few rooms in her house, staying far away from
the room where she had found her husband’s body.
Along with the emotional toll of losing her husband, Beth was burdened by
strong and complicated feelings about her husband and about the manner in which
he had died. She was angry at Adam for what she felt was his over use of pain
killers, but she also had a great deal of guilt about being out of the house when he
was choking. She was also adamant about her failure as a wife. Why couldn’t she
have been kinder, gentler, more giving, during their long marriage? ‘‘It would have
taken so little for me to make him happy. He wanted such simple things. Why
couldn’t I do those things?’’ Now that he was gone Beth realized how much she had
depended on his company and his affection. ‘‘No one else loves me except my
mother, and she’s 92 years old. She hardly knows me anymore, and she’s not going
to be around much longer.’’
Beth continued to work in the family’s business after her husband’s death, but
she wanted very much to retire. Outside of work, she had few interests and little
contact with her children and grandchildren. ‘‘I’m not much of a grandmother.
Adam was the one who would get down on the floor and play with them. I haven’t
been to see them, and I feel guilty about that too.’’
Beth bristled when discussing other people’s reactions to her grief, especially
their suggestions about her need for therapy, which she saw as having more to do
with their own needs than hers: ‘‘I think they just don’t want to listen to me
anymore.’’ The clinician validated Beth’s feeling that it was reasonable for her to
still be grieving after only a year, while at the same time suggesting other possible
explanations for her family’s concern, including Beth’s inability to stop thinking
about the day that Adam died and her intractable guilt about not having been there
to save him. Initially skeptical about the value of therapy, Beth found that she was
greatly relieved to be able to talk freely about her husband’s death, and all of the
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feelings related to it. She expressed her desire to be free of ‘‘this horrible guilt and
regret’’ so that she could ‘‘get back to living whatever kind of life I can have now.’’
In talking to Beth about her grief and the steps they would work on together, the
clinician described it as a ‘‘tear in the fabric of her life’’, a metaphor that borrows
from the description of grief as involving a loss of the assumptive world (Kauffman
2002). ‘‘When someone you love dies, it leaves a hole in your life, and that hole has
to be repaired’’ she explained to Beth. ‘‘Part of what’s been making it so hard for
you to deal with Adam’s death is that it was so sudden. You can’t stop thinking
about how he looked when you found him. You end up using a lot of energy trying
to avoid thinking about him, even about the good times you shared, because
thinking about him just makes you upset. You’re emotionally and physically worn
out, so you don’t feel like going out with people or seeing your grandchildren, and
that just makes you feel more alone.’’
The clinician suggested that to begin with, Beth needed some ways to calm
herself down when she was feeling upset. The simplest way to feel calmer, she
explained, is breathing, and at the end of the first session the clinician led Beth in a
breathing exercise that she could use throughout the day to ‘‘reset’’ herself and bring
her attention to something other than her emotional distress. This type of exercise
was one example of Self Regulation, the first of four parts of the work they would
do together. To repair the ‘‘tear in the fabric’’ of Beth’s life, they would also address
the anxiety, avoidance of triggers, social withdrawal and catastrophic thinking that
were complicating her grief.
‘‘You can think of this process of repair as making a new seam in the fabric.
There are four parts to this work. The first is Self Regulation—that’s about
learning to manage your emotions so that they don’t overwhelm you. The second
is Exposure—going to the places you’ve been avoiding and working through the
feelings that come up around the day that Adam died. The third is Activity—
every week we’re going to talk about what you’ve done to get yourself out of
the house and see people, and what you’ve done to get your body moving. The
fourth one has to do with paying attention to the way you talk to yourself—what
you say to yourself about Adam’s death, about your relationship, about your
future. That’s monitoring your thoughts and self talk. When you put these four
together you get: SEAM. Think of it that way, and it will make it easier for you
to remember.’’
Beth wrote ‘‘SEAM’’ on a piece of paper and tucked it into her purse. She also
took a drawing that the clinician made to illustrate the Dual Process Model of
Bereavement (Stroebe and Schut, 1999) which represents bereavement as a process
of oscillation between a focus on the loss and a focus on one’s life now and in the
future. ‘‘It’s helpful for me to think about it this way. Because this way, if I have a
bad day it doesn’t mean I’m going backwards. It’s just a bad day.’’
Using this template, Beth began to make a conscious effort to do something
related to each of the four elements of her treatment every week. In the beginning,
the clinician assigned her specific tasks, but soon Beth was reporting her own
initiatives. ‘‘My exposure activity this week was going to a restaurant that Adam
and I used to go to. I went with my son, the one who doesn’t like it when I talk about
Adam because I always start to cry. I told him that I want to be able to talk to him
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about his father. And when we talked about Adam, I thought about breathing and
talking slowly so I wouldn’t start crying.’’
Discussion of Cases
These brief vignettes illustrate a number of the points discussed here, and in other
accounts of CBT with bereaved clients (Malkinson 2012; Boelen et al. 2013). When
they began treatment, both Margaret and Beth were unable to fully believe that their
loved one had died. Both women felt guilty about the circumstances of the deaths
and also guilty about their failure in the role of sister or wife. In both cases, the
intrusion of thoughts and images related to the death were a constant source of stress
and misery. The decreased ability of both women to carry on with day to day tasks
made them question their competence and at times, their sanity. As the months
rolled by, they felt more and more hopeless about the future and less and less
convinced that they would ever ‘‘get back to normal’’.
The difficulties seen here are often present in cases of traumatic loss, and Boelen
et al. (2013) propose that they are rooted in the disconnection between memories of
the loss event and the rest of the bereaved’s memories and knowledge. The isolation
of loss specific memories leaves the bereaved person with an ongoing sense of
unreality about the death, while also leading to PTSD like symptoms of intrusions
and a continued sense of shock. Furthermore, the lack of integration interferes with
a person’s ability to redefine who they are without the deceased, a problem
particularly clear in Beth’s description of herself as unable to carry on without her
husband, and her vision of a bleak and lonely future. Along with the lack of clarity
about the self, there is a lack of adjustment to the ‘‘internalized representation of the
deceased to incorporate the reality of the death’’ (Shear and Shair 2005) in other
words, the bereaved is unable to develop a bond with their loved one that is based in
the understanding that they are no longer physically present (Rubin 1999; Rubin
et al. 2012).
The lack of accommodation to the reality of the death is also seen in Margaret’s a
focus on the abstract (why did it happen, why didn’t my brother ask for help) as
opposed to the concrete, a pattern the therapist sought to alter by having Margaret
think through the questions that continued to command her attention. In Beth’s case,
confrontation with the concrete involved homework assignments that directed her
toward exposure to reminders of her husband and the day of his death,
reengagement with her children and grandchildren, and reevaluation of negative
thoughts about herself.
It should be clear that the description of CBT in the cases included here
represents but a small piece of the overall treatment approach employed with these
individuals. Cognitive processing can facilitate emotional healing, but the pain of
grief does not arise simply because the bereaved person is thinking painful thoughts.
Grief, in short, is not only in the mind. Grief is physiologically dysregulating,
particular when it is traumatic in nature. Loss, particularly sudden loss, makes it
difficult or impossible for the bereaved to maintain a coherent sense of their world.
Reconsolidation of the intellectual self can only occur in tandem with emotional
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reregulation, and emotional reregulation is a process that occurs within the security
of relationship. The foundation of grief therapy (as in psychotherapy as a whole) is
the relationship between client and therapist (Norcross 2011; Kosminsky and Jordan
2016).
Conclusions
Is CBT Effective in Facilitating Adjustment to Loss?
The answer, as it is with respect to any and all interventions designed to help the
bereaved, is: sometimes. If there is one thing that experience has taught clinicians
who work with the bereaved, and that related research has done nothing to disprove,
it is that there are many paths to healing from loss and many ways of facilitating that
healing in cases where such assistance is deemed appropriate.
If history is any guide, the search for interventions specifically targeted to the
disorders catalogued in the DSM is not likely to reach a conclusion any time soon.
We would go so far as to say that with regard to grief, it is unreasonable to expect
such an outcome. Not every grieving person is able to benefit from structured
interventions for bereavement, including those based on CBT, and not every
clinician is trained, or inclined, to deliver them. In the most recent edition of his
classic work on bereavement in adult life, Colin Murray Parkes, writing with
researcher Holly Prigerson, notes that the success of CBT with depressed patients
‘‘has overshadowed other treatments and left counselors feeling deskilled…’’ . T h i s
result is particularly unfortunate and unnecessary when we consider that research on
what makes therapy effective has consistently identified the overarching importance
of the therapeutic relationship (Norcross 2011).
What Can We Hope to Achieve?
Like all healing, healing from loss is something that happens from the inside out.
The grief counselor supports this healing in many ways, one of which is to guide
the bereaved individual toward ways of thinking about their loss that make it
possible for them to assimilate and integrate it into their identity and their
understanding of the world. We can’t change reality by thinking about it in a
different way, but sometimes thinking about it in a different way can make reality
more bearable. This is, in the end, the essence of our work with the bereaved: to
help the mind find a way to accept what cannot be changed, and in so doing, to
find some kind of peace.
Compliance with Ethical Standards
Conflicts of interest The author declares that they have no conflict of interest.
CBT for Grief: Clearing Cognitive Obstacles to Healing…
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