A Guide To Cognitive Behavioral Therapy For Grief And Loss

Grief, whether from the death of a loved one or the end of a relationship, can be disruptive to daily functioning. Often, symptoms of grief improve with time, but some people experience grief that lingers for months or years. The persistent stress from chronic grief can adversely affect one's physical and mental health, with some individuals experiencing prolonged distress. For people experiencing loss, help is available through support groups and cognitive behavioral therapy (CBT) to improve symptoms effectively. 

An overview of grief

Some people assume that grief can only occur following someone’s death. However, grief is a common response to many types of losses, including:

• Death of a loved one (including pets)

• Loss of fertility

• End of a relationship

• Loss of a home, dream, or goal

• End of a job or career

• Loss of health, well-being, or youth

Some people experience distinct stages of grief responses. These stages can range from denial and anger to bargaining, depression, and acceptance. While many grieving people do not experience these stages, the following symptoms of grief are common: 

• Intense waves of emotions and extreme emotional fluctuation

• Feeling detached, numb, or empty

• Conflicting emotions

• Disbelief

• Sadness

• Fatigue

• Nausea

• Anger

• Relief

• Weakness

• Loss of interest in activities you used to enjoy

• Sleeping changes

• Appetite changes 

• Confusion and/or difficulty making decisions

Complicated grief 

Though grief tends to improve with time, some people experience symptoms that continue to interrupt daily life for more than a year after experiencing loss. This may be diagnosed as complicated grief, or prolonged grief disorder, which is common in cases of: 

• Absent grief: Absent grief is characterized by showing little outward signs of grief, which could limit social support.

• Ambiguous loss: This type of loss is often experienced when a loved one is still alive but feels distant due to circumstances such as incarceration, divorce, deportation, dementia, or another illness. 

• Disenfranchised grief: In some instances, grief may not feel socially acceptable (e.g., the death of a loved one from suicide or drug overdose).

• Traumatic grief: When death occurs under traumatic circumstances (i.e., natural disasters, violence, or accidents), it could lead to complicated grief and post-traumatic stress disorder (PTSD).  

Grief is an emotional reaction to loss that can be both personal and unpredictable. While there may be no reliable timeline for how long symptoms will last, grief can be classified as complicated grief if severe symptoms persist for more than a year. 

Common myths about the grieving process

There are many myths and misconceptions surrounding grief. These falsehoods can make the grieving process more difficult: 

Myth: Grief can only happen when someone dies

Grief can occur after many different types of losses. Bereavement specialist Terri Daniel explains that there are many types of grief that do not involve death, including estrangement, financial loss, worldly loss, illness, injury, relinquishment, and institutional loss. 

Myth: Grief is predictable

Everyone grieves in different ways, and many people do not experience the chronological “stages of grief” that were popularized by Elisabeth Kübler-Ross in 1969. Instead, an individual may experience complex emotions that fluctuate over time. Grief is not a linear process, and the intensity of negative emotions can vary greatly from one person to another. It's common for individuals to feel a connection to the deceased person, which can influence the way they experience and express their grief.

Myth: Mourning is a sign of weakness

Sometimes, the expression of grief is discouraged, and people are told to “move on” or “be strong” shortly after experiencing loss. However, grief is a natural experience, and when these difficult emotions are ignored, we may be more likely to develop maladaptive coping mechanisms, anxiety disorders, and depression. 

Myth: Grief goes away

While symptoms of grief tend to become less severe over time, they may never go away entirely. Grief is not an obstacle to overcome or avoid. 

Myth: If you’re not outwardly emotional, you don’t care

Grief is not the same as mourning, which is an outward expression of grief. Someone experiencing absent grief may experience their grief internally without showing signs of mourning. 

Myth: Grief does not have lasting effects on mental health

There's a common misconception that grief is purely an emotional response that doesn't have real implications on one's mental health. This overlooks the impact that intense or prolonged grief can have, potentially leading to conditions such as depression, anxiety, or complicated grief. Recognizing grief as a significant factor in mental health can encourage individuals to seek appropriate support and resources to work through their healing process effectively.

These misconceptions can make it more difficult for people to heal from loss. Sometimes, they drive people away from their emotions and social support, which can make complicated grief more likely to develop. 

What is cognitive behavioral therapy?

Unlike psychodynamic therapy, which focuses on how the past influences the present, cognitive behavioral therapy (CBT) focuses on coping with specific challenges like emotional distress and intense sadness by reframing unhelpful thought patterns. CBT is usually a short-term therapy that can provide clients with the tools to manage their symptoms on their own. In some cases, it may be combined with other types of therapy, such as art therapy, music therapy, and interpersonal therapy. 

CBT typically involves four stages: assessment, building awareness, cognitive restructuring, and behavioral activation: 

Assessing the problem

During this stage, your therapist may work with you to identify current challenges in your life, including grief. They might identify underlying problems like substance abuse or problems with family members that may be worsening or causing intense feelings. 

Building awareness

In this stage, your therapist can help you develop an awareness of the negative thought patterns surrounding your grief. They may ask you to examine your beliefs about yourself, how you interpret experiences, and how you talk to yourself. 

Cognitive restructuring

Once you become aware of your unhelpful thoughts and the emotional consequences they bring, you can begin the healing process by actively changing how you perceive and react to those thoughts. Through cognitive restructuring, a therapist can help you develop strategies to interrupt negative thought patterns and reframe them.

For example, imagine you are looking at social media and see that your friends are having dinner out and didn’t invite you. 

You may automatically think, “My friends think I’m too much of a downer now because all I talk about is my ex-girlfriend. They’re going to leave me like she did”. A therapist can help you challenge this thought and replace it with something like, “My friends texted me the other day to check in on how I’m doing. They care about me, and it’s okay that I’m not invited to every activity”. 

Behavioral activation (BA)

Like thoughts, behaviors can also influence feelings. Behavioral activation is a skill utilized in CBT to identify actions that positively or negatively impact mood. The goal of BA is to increase engagement in activities that positively impact emotions and decrease activities that are emotionally unhelpful. For example, you may realize that watching television or scrolling through social media makes you feel more isolated, whereas attending an exercise class may boost your mood and sense of community.  

In the context of grief and loss, research shows that CBT can improve grief acceptance and alleviate symptoms of complicated grief and PTSD. 

Can online CBT help?

Some people who are grieving experience debilitating symptoms like depression and extreme fatigue. If commuting to a therapist's office sounds exhausting, you may want to consider online cognitive behavioral therapy. Platforms like BetterHelp offer online CBT with licensed therapists specializing in grief counseling and clinical psychology. Plus, you can use in-app messaging to reach out to your therapist whenever you need guidance.

Research supports the effectiveness of online CBT for complicated grief. A randomized controlled trial found that online CBT significantly improved symptoms of complicated grief, and these improvements were maintained over time. A more recent study found that online CBT can effectively address symptoms of many other conditions, including depression, anxiety, and PTSD. 

One proposed study aims to evaluate online grief-specific CBT for persistent complex bereavement disorder, PTSD, and depression in individuals who lost loved ones during the COVID-19 pandemic. While the results are not yet published, the authors anticipate that online therapy effectively reduces symptoms.