Grief and Loss

Dr. Darlene Daneker & Maria C. Aiello


  • Grief can be defined as the “emotion, generated by an experience of loss and characterized by sorrow and/or distress and the personal and interpersonal experience of loss” (Humphrey, 2009, p.5). Grieving after a significant loss, the death of a loved one or other loss, is a normative process. Most people proceed through this process with help of family, friends, community support, or alone without complications. However, a significant minority of people develop complications in this process. 
  • Complicated Grief is a “debilitating clinical condition that can develop after the death of a loved one” (Boelen, Keijser, van den Hout & van den Hout, 2007 p. 277). It is important to note that complicated grief can stem from the death of a loved one but can also occur in grief situations unrelated to death, including, but not limited to, the loss of a job, a geographical move, or a divorce. An estimated 10 to 15 % of bereaved individuals develop complicated grief experiencing symptoms of intense yearning for the lost loved one, intrusive and troubling images or thoughts of the death, feelings of inner emptiness, difficulty accepting the reality of the loss, and difficulty trusting others (Howarth, 2011; Neimeyer & Currier, 2009). It is important to note that complicated grief is often clinically noticeable in that the person appears “stuck” in the grieving process. Where, and why, the person is stuck is critical to identify in the therapeutic process. The “sticking point” is where intervention is needed.
  • Complicated grief is associated with clinically significant distress such as sleep disturbances (Germain, Caroff, Buysse, Shear, 2005; Maytal, Zalta, Thompson et al., 2007), suicidal thinking and behavior (Latham & Prigerson, 2004; Mitchell, Kim, Prigerson, Mortimer, 2005; Szanto, Shear, Houck, et al., 2006), increased use of alcohol and tobacco (Hardison, Neimeyer, Lichstein, 2005; Prigerson, Horowitz, Jacobs, 2009), and impaired relational functioning (Hardison, Neimeyer, Lichstein, 2005). In cases where the loss is combined with trauma such as a sudden death, a violent death, or a loss outside the life expectations and experiences of the individual complicated grief may also develop with symptoms of post traumatic stress disorder (Nakajima, S., Ito, M., Shirai, A., & Konishi, T., 2012).


  • The ACA defines counseling as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (American Counseling Association, 2010). Grief is a developmental milestone which directly affects the mental health of every individual over the course of his or her life. Complicated grief is a developmental process that is not proceeding in a healthy man- ner and is causing significant distress to the client.
  • According to US government statistics, approximately 36% of the population is grieving at any given time with approximately 10-15% of those developing complicated grief (Howarth, 201; Neimeyer & Currier, 2009).
  • There is a possibility of an increase in demand for grief therapy as veterans are seeking services to assist them with dealing with the vast amount of losses they may encounter.


Identification/Assessment Strategies

Symptoms of Complicated Grief submitted for consideration of inclusion in the DSM-V include:

A.  Event criterion: Bereavement (loss of a loved person). 

B.   Separation distress: The bereaved person experiences at least one of the three following symptoms that must be experienced daily or to a distressing or disruptive degree:

      1. Intrusive thoughts related to the lost relationship.
      2. Intense feelings of emotional pain, sorrow, or pangs of grief related to the lost relationship.
      3. Yearning for the lost person.

C.  Cognitive, emotional, and behavioral symptoms:
      The bereaved person must have five (or more) of the following symptoms:

1. Confusion about one’s role in life or diminished sense of self (i.e., feeling that a part of oneself has died).
2. Difficulty accepting the loss.
3. Avoidance of reminders of the reality of the loss.
4. Inability to trust others since the loss.
5. Bitterness or anger related to the loss.
6. Difficulty moving on with life (e.g., making new friends, pursuing interests).
7. Numbness (absence of emotion) since the loss.
8. Feeling that life is unfulfilling, empty, and meaningless since the loss.
9. Feeling stunned, dazed, or shocked by the loss.

D. Duration: Diagnosis should not be made until at least six months have elapsed since the death.
E.   Impairment: The above symptomatic disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (e.g., domestic responsibilities).
F.   Medical exclusion: The disturbance is not due to the physiological effects of a substance or a general medical condition.
G. Relation to other mental disorders: Not better accounted for by Major Depressive Disorder, Generalized Anxiety Disorder, or Posttraumatic Stress Disorder. (Prigerson, Horowitz, Jacobs, Parkes, Aslan, et al. 2009;  Simon, Wall, Keshaviah, Taylor, Dryman, LeBland, Shear, 2011).

  • The Brief Grief Questionnaire (Shear, Jackson, Essock, Donahue, Felton, 2006) is a five item self report survey scored on a three point Likert type scale with one scoring lowest and three highest. Higher scores indicate greater distress. This screening instrument is supported for identifying Complicated Grief (Ito, Nakajima, Fujisawa, Miyashita, Kim, Shear, Ghesquiere, & Wall, 2012). This screening instrument is available through plosone, a free access public portal to scholarly, peer reviewed articles.

Treatment for Complicated Grief

There is a paucity of research on the efficacy of treatment for complicated grief. Early research on grief therapy failed to differentiate between “normal” grief processes and complicated grief (Neimeyer & Currier, 2009). Once this issue was taken into consideration it was found that broad community treatment for grief is ineffective, and may be detrimental while identification and treatment for those with complicated grief shows impressive results (Neimeyer & Currier, 2009; Boelen, Keijser, van den Hout & van den Hout, 2007; Rosner, Pfoh, Kotoucova, 2011). In their “dual process model” (Stroeb & Schut, 1999) described a process of approaching the pain of the loss by talking about the deceased, viewing pictures, utilizing guided imagery to “talk” to the deceased person, or writing letters to the deceased alternating with periods of avoiding the pain of the loss and focusing on current and/or future goals such as learning new skills to be successful in life without the deceased, hopes for future happiness, and constructive positive thinking.

One evidence-based procedure is Complicated Grief Therapy (Shear, Frank, Houch, & Reynolds, 2005) which involves specific procedures to help the grieving individual directly approach the painful aspects of the loss and, at other times, focus on current and future goals. This treatment is based in Attachment theory and was conducted over 16 weeks and was compared to interpersonal therapy. This treatment approach demonstrated greater healing than interpersonal therapy.

Resource: Wetherell, (2012) Complicated grief therapy as a new treatment approach. Dialogues in Clinical Neuroscience. 14, (2), 159-166.

Resource: Rosner, R., Pfoh, G. & Kotouc, M. (2011). Treatment of complicated grief. European Journal of Psychotraumatology, 2. doi:10.3402/ejpt.v2i0.7995

Both resources contain multi session outlines based on theory supported by current research as being effective with complicated grief. Most approaches using the Dual Process Model follow similar protocol of discussing the difficult aspects of the loss alternating with discussions of positive coping such as learning to cook, meeting new people, or finding meaningful work. Faulty cognitions identified in the discussions of the loss are challenged by exploring and “gathering evidence” of the truth of these beliefs. The client may then examine the “evidence” and, confronting the discrepancy with reality, change their thinking. The client is then helped to find meaning in the loss to create a new world view that is changed from the one held prior to the loss.

Cognitive Behavioral Therapy practices also have been found in many descriptions of treatment of complicated grief and have been shown to be more effective than supportive therapy or no therapy (Boelen, Keijser, van den Jout & van den Hout, 2007) by helping individuals identify and change maladaptive cognitions and behaviors (Mathews & Marwit, 2004).

Resource: Beck Institute for Cognitive Behavior Therapy:


Beck Institute for Cognitive Behavior Therapy:

Boelen, P. A., de Keijser, J. D., van den Jout, M. A., & van den Hout, J. (2007). Treatment of complicated grief:  A comparison between cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 75, 277-284.

Germain, A. Caroff, K. Buysse, D.J. Shear, M. K. (2005). Sleep quality in complicated grief. Journal of Traumatic Stress, 18 (4), 343-346.

Hardison, H. G., Neimeyer, R. A., Lichstein, K.L. (2005) Insomnia and complicated grief symptoms in bereaved college students. Behavioral Sleep medicine, 3 (2), 99-111.

Howarth, R. A. (2011). Concepts and controversies in grief and loss. Journal of Mental Health Counseling, 33 (1), 4-10.

Humphrey, K.M. (2009). Counseling  strategies for loss and grief. Alexandria,  VA: American Counseling Association. Latham, A. E. and Prigerson, H.G. (2004). Complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide and Life threatening behavior. 34 (4), 350-362.

Maytal, G. Zalta, A.K., Thompson, E. Et al. (2007). Complicated grief and impaired sleep in patients with bipolar disorder. Bipolar Disorder, 9 (8), 913-917.

Mitchell, A. M., Kim Y., Prigerson, H.G., Mortimer, M. K. (2005). Complicated grief and suicidal ideation among young adult survivors of suicide. Suicide and life threatening behavior, 35 (5), 498-506.

Nakajima, S., Ito, M., Shirai, A., & Konishi, T. (2012). Complicated grief in those bereaved by violent death:  The effects of post-traumatic stress disorder on complicated grief. Dialogues in Clinical Neuroscience, 14(2)210-213.

Neimeyer, R. A. and Currier, J. M. (2009). Grief therapy: Evidence of efficacy and emerging directions. Current Directions in Psychological Science, 18 (6), 352-356.

Ober, A.M., Granello, D.H., and Wheaton, J.E. (2012). Grief counseling: An investigation of counselors’ training, experience, and competencies. Journal of Counseling & Development, 90: 150-159. doi: 10.1111/j.1556-6676.2012.00020.x

Prigerson H. G, Horowitz M. J, Jacobs S. C, Parkes C. M, Aslan M, et al. (2009) Prolonged grief disorder:  Psychometric validation of criteria proposed for DSMV and ICD-11. PLoS Med 6(8). doi:10.1371/journal. pmed.1000121

Rosner, R., Pfoh, G. & Kotouc, M. (2011). Treatment of complicated grief. European Journal of Pschytraumatology2. doi:10.3402/ejpt.v2i0.7995

Shear, M. K. Frank, E., Houch, P. R. & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. JAMA, 293, 2601-2608.

Shear M. K, Jackson C. T, Essock S. M, Donahue S. A, & Felton C. J (2006) Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatric Services, 57: 1291–1297.

Shear, K. M. (2012). Grief and mourning gone awry: Pathway and course of complicated grief.
Dialogues in Clinical Neuroscience, 14, (2) 119-128.

Simon N., Wall, M. M., Keshaviah, A., Taylor, M., Dryman, LeBlanc, N. J., Shear, K. M. (2011). Informing the  Symptom Profile of Complicated Grief Depress Anxiety, 28, (2) 118–126. doi:10.1002/da.20775.

Stroebe, M. & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197-224.

Szanto, K. Shear, M.K., Houck, P.K. et al. (2006). Indirect self-destructive behavior and overt suicidality in patients with complicated grief. Journal of Clinical Psychiatry, 67 (2), 233-239.

Published: February 2015
Updated: August 2016