Complicated Grief Therapy: The Complete Overview

Grief is a complex and devastating emotion that people often experience after a significant loss or a great trauma has occurred in their lives. Complicated grief therapy seeks to help people deal with a significant loss in healthier ways.

So, what is complicated grief therapy? Complicated grief therapy uses a type of cognitive-behavioral therapy to help patients who are suffering from complicated grief. It is more specific to their symptoms than other therapies.

While grief is normal, those with complicated grief continue suffering even after a long period of time passes (often a year or more after the loss), and they find it nearly impossible to return to their everyday life. There are different options for helping those struggling with complicated grief, and complicated grief therapy is one of the most effective methods for dealing with complicated grief.

How is Complicated Grief Therapy Different from Other Treatment?

Complicated grief therapy is a specific type of cognitive-behavioral therapy tailored to patients experiencing complicated grief. Therapy that is not targeted towards grief specifically is significantly less effective. One study showed that Interpersonal psychotherapy was not as successful at treating complicated grief as CBT based complicated grief therapy.

Interpersonal psychotherapy is good for dealing with negative emotions that are associated with grief, but it doesn’t deal with the specific experiences of loss and death. Specific goals for patients undergoing complicated grief therapy are:

  • Thinking about the loss of the loved one in a more helpful way
  • Reduce feelings of anxiety, guilt, or anger
  • Returning to a satisfying life without the loved one

 The goal of complicated grief treatment is to help the patients recognize negative emotions and give them the tools to be able to deal with those negative emotions in a healthy way. This can allow the patient to:

  • Better recognize and enjoy their positive emotions when they come
  • Give them a healthier relationship with the people around them
  • Help them accept the finality of loss

It is unlikely that the person suffering from complicated grief will never experience sadness or other grief symptoms ever again, but complicated grief therapy seeks to decrease the frequency in which the patients experience acute grief symptoms. Rather than the older model of grief as five stages, experts today usually think of grief as a transition from acute grief to integrated grief. Complicated grief treatment then seeks to encourage the transition from acute grief to integrated grief.

Stages of Grief

Experts categorize grief differently from the older five stages model. Now, they recognize two stages with the understanding that grief itself is permanent, but it changes over time as the person adapts to the loss.

 1. Acute Grief

Acute grief is the initial phase of grief. This period often occurs up to several months after the bereavement. There are often feelings of intense and debilitating sorrow. People often have strong feelings of:

  • Depression
  • Anxiety
  • Anger

 Those in the acute stage of grief often feel extreme separation distress because they are afraid of not having their loved one around anymore. They are unsure of how to continue without them. They experience overwhelming feelings of emotional pain, which may even feel like physical pain in your body.

Physical experiences of acute grief can also include:

  • Heart palpitations
  • Upset stomach
  • Brain fog and dizziness
  • Dissociation from reality
  • Trouble focusing

 2. Integrated Grief

Integrated grief comes after the period of acute grief. It is the lasting grief that will remain permanent in the bereaved person’s life, but it is no longer a dominating factor as they have come to terms with the loss and learned to adapt.

Bereaved people are able to once again enjoy pleasurable activities, resume their normal lives, and focus on other relationships once again. However, this does not mean that the person has forgotten their loved one, but they are no longer severely triggered by reminders. They have finally accepted the loss while still feeling connected to their loved ones.

However, acute grief can return during certain times where the memories of the loved one are very strong. This doesn’t indicate any failure on the part of the grief sufferer, it is simply a natural part of the grieving process. Events in which may cause acute grief to return include:

  • Important holidays
  • Birthdays
  • Anniversaries
  • Another loss
  • Stressful Events

 3. Complicated Grief

Complicated grief is a persistent form of acute grief that dominates the life of the bereaved person. Acute grief normally lasts around six months. When the stage of acute grief continues for a very long time (a year or more), it often indicates that the person is having trouble accepting the reality of death and is experiencing complicated grief.

 Attachment Theory in Complicated Grief Therapy

There is a form of complicated grief therapy that combines some interpersonal psychotherapy techniques and focuses on attachment therapy to help relieve patients of their distress.

Attachment theory is based on the belief that humans are biologically programmed to:

  • Seek interpersonal relationships
  • Form interpersonal relationships
  • Maintain interpersonal relationships

It is this balance of emotion involved in these relationships that can have and affect how we deal with loss.

Attachment theory in psychology is usually used to describe a child’s attachment to their primary caregiver, but this model can be used in any close personal relationship. There are three types of attachment styles:

  • Secure
  • Avoidant
  • Resistant

The resistant attachment style is the one that indicates a child will experience intense emotional distress when their primary caregiver leaves with virtually no ability to be consoled. This indicates how complicated grief can affect some sufferers, and how treatment can more accurately help them.

Within this theory, professionals believe that people’s interpersonal relationships are categorized with distinct types of attachments. People have certain “attachment figures” who are people with whom they routinely seek closeness and resist separation. You view them as a place for safety and security where you can explore the world with little risk because they are with you.

During the stage of acute grief, this attachment relationship is completely disrupted, and the person is left feeling lost and devastated. It is after mourning and integration of the loss into the person’s life that acute grief transforms into integrated grief, but with some patients, the acute grief remains and becomes long-term, prolonged complicated grief.

With attachment theory implemented into therapy, patients can begin to recognize the ways in which they used to rely on their loved ones. Once this is recognized, they can then begin to adjust and deal with their surroundings and stressors in healthy ways.

Themes of Complicated Grief Therapy

One comprehensive study of the effectiveness of complicated grief therapy on complicated grief patients outlined seven major themes covered in the treatment that helped the patients on their journey to recovery:

  1. Understanding and accepting grief
  2. Managing emotional pain
  3. Thinking about the future
  4. Strengthening ongoing relationships
  5. Telling the story of death
  6. Living with reminders
  7. Connecting to memories

Using these themes, complicated grief therapy was a much more effective treatment than interpersonal psychotherapy and other traditional forms of cognitive behavioral therapy. The first theme of understanding and accepting grief allows patients to conceptualize what they’re feeling. Many people may expect them to simply snap out of it and return to normal after a certain period of time, but many sufferers may not even have the words to describe how they’re feeling.

Additionally, a risk factor for complicated grief is being unable to manage emotional pain. In dealing with your emotions and facing them head-on, it will become much easier to think about the future without the loved one that you lost and continue fostering your current relationships.

People are uncomfortable talking about death, which can be the root of the problem in terms of avoiding painful memories of the deceased or even not being able to let go of the memories for fear of losing them. Coming to terms with the death and realizing the finality of it and the inevitability of it can help sufferers heal and adapt to their new life changes.

Adaptation in Complicated Grief Therapy

The biggest focus in Complicated grief therapy is helping patients adapt to their new circumstances in the absence of their loved ones. Complicated grief not only affects the patient’s mental health and well-being but also can affect their physical health. In addition to mental health issues such as depression and anxiety, people dealing with complicated grief may experience:

  • Sleep Disturbances
  • Physical Illness
  • High Blood Pressure
  • Substance Abuse

Because of these symptoms patients often have trouble returning to their normal lives, and through the overarching themes of complicated grief therapy, they can learn how to transition from acute grief to integrated grief.

Adaptation can occur with the help of a mental health professional to fully process the consequences of death. This often involves retelling the story of what happened so that the patient can begin to conceptualize the events and come to terms with them.

Tools Used in Complicated Grief Therapy

Psychologists will use several different techniques to help their patients during their counseling sessions. They tailor the sessions to the specific needs of the patient, but some common tools used during complicated grief therapy include journaling, visualization, and storytelling.


Writing things down is a common therapy tool, and in complicated grief therapy, patients will use journals to write down their emotions during their day. The therapist will usually ask the patient to take note of emotional triggers and any stressful moments that they experience throughout the day.


This is a technique commonly used for sufferers of PTSD. The therapist may have the patient visualize certain moments with their deceased loved one or even the moment they found out about their death. This allows the patient to begin emotionally processing the events.


This is similar to visualization, but it can help patients become more comfortable talking about their loved ones by telling stories about them. The therapist may have them tell the story of their death, but they may also tell other stories and memories about the deceased person as well.

Other Treatments for Complicated Grief

There are multiple ways that complicated grief can be treated. Some mental health professionals may prescribe antidepressants, though the most common and most effective form of treatment for complicated grief is psychotherapy. In one study, most patients improved more significantly when they participated in therapy specific to complicated grief.

Though antidepressants are sometimes prescribed to treat complicated grief, they are rarely used. The goal of treatment is not for the patient to get over the death of their loved one or forget about it, but it is to help them come to terms with the death and learn to deal with their emotions in a healthy way. The other more popular forms of treatment are:

  • Cognitive Behavioral Therapy
  • Interpersonal Psychotherapy
  • Complicated Grief Therapy

Complicated Grief Therapy is simply a specific type of Cognitive Behavioral Therapy that is designed to cater to the needs of complicated grief patients. Interpersonal Therapy is the outlier that does well for other mental health problems but doesn’t do so well in easing the troubles of complicated grief sufferers.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is the most popular and the most widely used form of psychotherapy treatment for many mental health disorders and issues, even going beyond grief. It has been well studied and well documented, and it has had a large amount of success in treating many different psychological conditions. This has made it a staple in the treatment options for mental health.

CBT is based on the belief that many of the difficulties people face in their mental health have to do with negative, pervasive, and unhelpful thoughts. Those negative thoughts can create negative emotions and behaviors that negatively impact a person’s life. CBT attempts to change those negative thoughts into positive ones and thus improve the person’s emotional well-being.

The goals of CBT are to:

  • Identify one’s negative thoughts
  • Determine if these thoughts are helpful or unhelpful
  • Correct negative thoughts

These sessions can be done one on one or in a group setting. Especially in treating grief, group sessions have been shown to be particularly helpful in creating a community of support so that patients no longer feel so alone.

 Interpersonal Psychotherapy

Interpersonal psychotherapy is a form of therapy that focuses more on the emotions of the patient. The patient is encouraged to examine the connection between their emotions and traumatic life events.

This often involves examining the patient’s interpersonal relationships and focusing on creating healthier relationships with others. Interpersonal psychotherapy has been known to be quite successful in patients who hold a lot of blame for themselves. With therapy, they can begin to see themselves as a part of a community again and learn that they don’t need to take responsibility for everything in their lives.

What Causes Complicated Grief?

Doctors and psychologists aren’t entirely sure what causes complicated grief. While the feelings of grief are completely normal, they usually fade over time as people adjust back into their normal lives. However, those suffering from complicated grief respond differently. They often feel as though:

  • Life has no purpose or meaning
  • Their life has been irreparably changed by this loss
  • They can’t imagine feeling good again

Many people think that complicated grief must happen when the sufferer’s relationship with the deceased was tumultuous and fraught with tension. However, anyone can experience complicated grief, and it actually happens more often to people who had a beautiful and fulfilling relationship with the deceased person.

The person suffering from complicated grief misses the person that they lost so dearly that they find it hard to move forward. Often, they are stuck in thoughts of the past. They are stuck in thoughts of ‘What if?’ This inability to move forward can keep them in a cycle of grief and sadness that never ends.

Some people with complicated grief actually end up becoming attached to their grief. They may believe that if they let go of their grief and sadness that they are somehow disrespecting the loved one that they lost. They believe that moving on means that they will start to forget them. And even others with complicated grief may feel tired of grieving, but they still wish to keep the memory of their loved one alive, and they just don’t know how to move on.

Symptoms of Complicated Grief

The first few weeks and months after a loss can look mostly the same among those who have lost a loved one. The feelings of grief are completely normal. However, grief normally begins to fade over time and the person begins to return to their normal, everyday activities. In a person with complicated grief, their feelings will continue for much longer. Their pain is ongoing and it stops them from healing and moving forward.

Symptoms of complicated grief may include:

  • Intense sorrow, pain, or despair
  • Constantly thinking about the loss of the loved one
  • Avoidance of reminders of the loved one
  • Extreme attention to reminders of the loved one
  • Difficulty with other relationships
  • Numbness and disinterest
  • Isolation from normal life and activities
  • Feeling guilt, shame, depression, or self-blame

It is common for all people who have recently experienced a loss to occasionally feel these things. However, those feelings usually pass as the person comes to terms with their loved one’s death.

People experiencing complicated grief will have many troubling thoughts about how things could have been different. They imagine what they would have said to their loved one if they’d had the chance. They might blame themselves for not being able to help or save them. People with complicated grief get stuck in these spirals of thinking and cannot get themselves out.

Complicated grief sufferers may also aggressively avoid all reminders of their loved one because they have trouble managing their difficult emotions. This avoidance doesn’t allow them to heal or eventually accept their loved one’s death. Other people may actively and aggressively seek out reminders of their loved one because they believe they must constantly live in the intense emotions of grief and sorrow. They believe it is the only way to keep their loved one’s memory alive.

Risk Factors for Complicated Grief

Of all the people who experience a big loss in their lives, it is estimated that 12-15% of them will experience complicated grief. Millions of people suffer from this condition, and they don’t even realize it. They don’t know that they can reach out for help.

While there is still no known cause for complicated grief, there are several different circumstances that indicate a stronger likelihood that a person may suffer from it:

  • Unexpected or violent death (car accident, murder, or suicide)
  • Very close or dependent relationship
  • Death of a child
  • Lack of strong support system or close friendships
  • Insecure attachment style
  • History of depression, anxiety, or PTSD
  • Trauma
  • Major life stressors (financial difficulties, etc)

What can commonly happen in sufferers of complicated grief is that they desperately wish for a different outcome. They may replay moments over and over again in their heads wondering what they could have done differently to have saved their loved one. Patients often deal with many negative emotions. This often will include emotions like:

  • Regret
  • Failure
  • Anger

These feelings can become a significant problem if the person gets trapped in their negative thoughts. Once trapped in those thoughts it will become increasingly difficult to learn to adapt to the loss.

Managing emotions is also an important skill to have if one is to avoid complicated grief. While others experiencing loss may use other activities to diffuse their emotional pain or lean on their loved ones for support, people with complicated grief will have trouble doing this. They don’t know how to manage their emotions in a healthy way, and it will begin to negatively impact other parts of their lives.

Preventing Complicated Grief

Since the cause of complicated grief isn’t entirely known, it isn’t always easy to prevent it. However, knowing the risk factors (listed above) can be a helpful tool in realizing when complicated grief could occur. After a devastating loss, there are a few things that can be helpful in dealing with grief.


It is especially important to talk about your feelings after a traumatic event. This is one of the most helpful tools for managing your emotions because you aren’t keeping your feelings bottled up inside. If you need to have a good cry, do that as well.

Lean on Others

Gather people around you that you trust and use them as your support system. In times of great stress and trauma, it is important to not be afraid to ask for help. Talk to your loved ones around you, or even look for grief support groups to speak with other people who are experiencing the same things as you.

Get Counseling

Once again, don’t be afraid to ask for help. If you feel it would be helpful to speak with a professional about how you are feeling, there are many options for bereavement counseling. The options listed in this article can help specifically target your experiences with grief and help you learn to deal with them.

What to Do if You or a Loved One are Experiencing Complicated Grief

Recognizing the signs and symptoms of complicated grief is a very important first step in recovery and healing. Be sure that you understand all of the warning signs, symptoms, and risk factors to determine if you or your loved one are suffering from complicated grief.

An important next step would be to see a doctor or physician who can refer you to a trusted mental health professional. A psychologist will offer you treatment that can improve your symptoms and eventually get you back to normal life.

With the depression that can accompany complicated grief, some people may experience suicidal thoughts. If you are having suicidal thoughts, contact a mental health professional. If you believe you might act on those thoughts call 911 or call a suicide hotline number.

Helping a Loved One Who Has Complicated Grief

If you think that someone you know may have complicated grief, it may be beneficial to suggest that they see a mental health professional. They will be better able to assess your loved one’s needs. Don’t give them a diagnosis yourself and be gentle in your suggestion to see a professional.

It is important to note that it is not this person’s fault that they are experiencing complicated grief. Mostly, it is important to be there to support them as they are dealing with their grief and as they go through complicated grief treatment. Help them practice stress management, and be the consistent, gentle encouragement that they need.

If you or someone you know is struggling with complicated grief, there are treatment options available. Do your research and find the best option for you.

Written by Kasia Ciszewski, LPC on

Kasia is a licensed professional counselor servicing the Charleston area. She helps individuals heal, better understand their emotions, energize & become more aware of their inner strength. She specializes in helping teens, adults and seniors and has been able to regularly achieve impressive results for her clients throughout South Carolina. Instagram - Facebook - Pinterest - Twitter - Linkedin

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