When Time Doesn’t Heal

Treatment for Complicated Grief
By Sharon Tregaskis | Illustrations by Davide Bonazzi

When 13-year-old Eric Muldberg died of bone cancer in February 2004, his mother was heartbroken. Four years passed and still Stephanie Muldberg felt as raw as the night Eric had died. Numb and increasingly isolated, she went through the motions of cooking, cleaning, and getting her daughter to school. Many days, she simply took the phone off its hook to avoid interactions with the outside world.

“I had wonderful, caring therapists,” says Mrs. Muldberg, who imagined that her intense, debilitating grief was typical of any parent who has lost a child. “I assumed that my life had been irreparably damaged by the loss of my son and I could not imagine ever feeling better. Grief dominated my life. It was as if Eric had just died yesterday.”

Then, in 2008, a health care practitioner put Mrs. Muldberg in contact with M. Katherine Shear, MD, the Marion E. Kenworthy Professor of Psychiatry and director of Columbia’s Center for Complicated Grief (www.complicatedgrief.columbia.edu). Dr. Shear diagnosed the bereaved mother with a condition known as “complicated grief.” Through Dr. Shear’s unique 16-week program—an evidence-based treatment using targeted strategies derived from interpersonal therapy, motivational interviewing, positive psychology, and cognitive behavioral therapy—Mrs. Muldberg was able to envision a life of joy and satisfaction after the profound loss she had suffered.

Instead of avoiding reminders of the vital moments her son could no longer enjoy—visits to his favorite sandwich shop, hitting a baseball at the local park—Mrs. Muldberg could finally cherish her memories of those happy times and fully embrace opportunities for joy, even if Eric could not share in them. “I was able to engage in life again, not feel guilty about living,” says Mrs. Muldberg, who is now in her early 50s. “I was better able to take care of myself, exercise self-compassion, and recognize there would be triggers. I was able to integrate the loss.”

Think of the mourning process as somewhat like the turmoil we experience when we fall in love, suggests Dr. Shear. “Grief is the form love takes when someone we love dies,” says Dr. Shear. “It evolves over time, seeks its rightful place in our lives. You don’t forget the person and you still feel sad that they’re gone, even decades later.”

Typically, in the aftermath of a loved one’s death we experience a period of acute grief; it is emotionally intense, preoccupies our thoughts, disrupts our ability to function. Through the process of mourning, however, we heal. We come to terms with the loss, integrate our new reality, and find ways to honor a loved one’s memory even as we carry on our lives without them. “We have a natural biological capacity to heal or adapt to a loss, even the most painful,” says Dr. Shear. “When someone is having trouble, it’s because something is interfering.”

Consider, for example, wound healing. Typically, the immune system mounts a defense; if that process goes awry, infection results. When mourning goes awry, “complicated grief” emerges. Dr. Shear estimates that 7 percent to 10 percent of bereaved survivors—most often women who have lost someone especially close, such as a child, parent, or spouse—experience the condition. “A couple of things we think are risk factors for complicated grief are more common for women,” says Dr. Shear. “Women, on average, are more likely to be ruminators and women are also more likely to have difficulty practicing self-compassion.”

In more than 100 papers published over the past two decades, Dr. Shear and her co-authors have developed diagnostic criteria for complicated grief; documented how the condition boosts risk for such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits; assessed demographic and psychological predictors of complicated grief; and tested the unique treatment strategy that helped Mrs. Muldberg reclaim her sense of purpose.

While some of the symptoms of complicated grief overlap with both clinical depression and anxiety disorders, complicated grief rarely responds to conventional treatments for either.

Dr. Shear’s work in the field got its start in the mid-90s, when she joined the psychiatry faculty at the University of Pittsburgh. A team of her colleagues there—including Barnard College graduate Holly Prigerson, PhD, and Charles F. Reynolds III, MD—had published papers on the symptoms of complicated grief in Psychiatry Research and the American Journal of Psychiatry that showed that symptoms were distinct from those of bereavement-related depression and anxiety and associated with enduring dysfunction. When Dr. Shear joined the team, they began exploring treatment strategies.

Since then, Dr. Shear and her colleagues have documented how complicated grief frequently co-occurs with clinical depression and shown that people who have suffered clinical depression in the past are more likely to experience complicated grief. While some of the symptoms of complicated grief overlap with both clinical depression and anxiety disorders, complicated grief rarely responds to conventional treatments for either.

Thus, as with Mrs. Muldberg, millions of people suffering complicated grief remain seized in its grip even as they diligently work with therapists treating them for depression. “The notion of complicated grief is gaining increasing recognition, but in some ways it’s relatively new—and because it does so often co-occur with depression, it’s understandable why diagnoses might be incomplete,” says Dr. Reynolds, now the University of Pittsburgh Endowed Professor in Geriatric Psychiatry and director of the John A. Hartford Center of Excellence in Geriatric Psychiatry, who was co-author with Dr. Shear and Dr. Prigerson of many of their foundational studies.

Locked indefinitely in the throes of a painful loss, people with complicated grief ruminate on circumstances of the death, worry about its consequences, and avoid reminders of the loss. Unable to come to terms with the finality and consequences of their loss, they go to extremes to avoid the intense emotion triggered by reminders. Years, even decades after the loved one’s death, they remain stuck, unable to imagine a life of joy and purpose without their beloved, their psychological and physical health increasingly compromised.

“Dr. Shear is an absolutely superb physician,” says Dr. Reynolds, who has co-authored 45 papers with her, including several with Dr. Prigerson advancing the case for including complicated grief in the fifth edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders.” “Her development of assessment and treatment is very much grounded in her clinical experience, taking care of people living with complicated grief.” The result, says Dr. Reynolds, is a rich synergy. “There is a wonderful two-way interaction between her experience as a bedside clinician and her great work as a scientist. They inform each other. There is a wonderful clinical relevance and freshness to her work, which is borne of the countless hours she has spent with these patients.”

Dr. Shear’s approach to treatment relies on a particularly powerful lesson the psychiatrist has gleaned from her years working directly with patients: People suffering complicated grief have extraordinary resilience and the capacity to heal. They just need help clearing the interference. “Our treatment supports what we understand to be the generic healing process,” she says. “We’re looking for roadblocks to that in terms of certain beliefs and avoidance and escape behaviors and difficulty with regulation of emotions.”

The 16-week treatment protocol—tested in three NIH-funded randomized controlled trials—yields relief, on average, for 70 percent of patients. Called CGT (complicated grief treatment), the protocol focuses on three components of the mourning process: accepting the reality of the death, developing an ongoing relationship with the person who died, and envisioning a future in which the beloved is no longer physically present but possibilities for joy and happiness remain. “People we love are mapped in our brains and we don’t know how to erase memories,” she says. “They’re still there.”

In addition to weekly sessions with a trained therapist, CGT participants have daily tasks—homework, if you will—to perform between sessions. In the second session, the patient sets goals for his or her recovery; each subsequent session features reflection on progress toward those aspirations. In the third session, the patient brings a friend or loved one as part of an emphasis on rebuilding connections with living loved ones. Patients also keep a grief intensity diary to review with the therapist at each session, and in a component evocative of PTSD therapy, therapists record their patient telling the story of the death, then ask the patient to listen to the recording each day. As the patient makes peace with the loss, the therapist asks the patient to identify situations—people, places, or things—she or he has been avoiding because they trigger painful reminders. Together, patient and therapist generate a plan for the patient to confront one of those reminders. Finally, the therapist helps the patient consolidate memories of good and bad times shared with the loved one.

In a study published by JAMA Psychiatry in July, researchers tested the benefits of an antidepressant alone or in combination with CGT. The study again confirmed the efficacy of CGT. “Dr. Shear has truly led the way in creating an innovative psychotherapeutic approach to helping persons living with complicated grief,” says Dr. Reynolds, who co-authored the paper.