CCBT for Grief and Loss

Grief Support · Andreas Grivas, MSc Clinical Psychologist · May 05, 2023

CCBT for Grief and Loss

Grief is the natural response to losing someone we love. Sadness, longing, disbelief, anger, guilt, disturbed sleep and difficulty concentrating are common in the weeks and months after a death, and for most people the intensity gradually softens as they find ways to carry the loss into their ongoing lives. For a minority, however, grief remains intense, persistent and disabling. This pattern is now recognised as prolonged grief disorder in both ICD-11 and DSM-5-TR. Its core features are an attachment disturbance marked by intense yearning for, or preoccupation with, the deceased, together with symptoms such as identity disruption, a sense that life has lost its meaning, emotional numbness, intense emotional pain and marked avoidance of reminders of the loss, persisting well beyond what is expected in the person's culture (in DSM-5-TR, at least 12 months after the death for adults). Validation work has shown that this diagnosis is distinct from depression, post-traumatic stress disorder (PTSD) and generalised anxiety, and is stable over time (Prigerson et al., 2021).

How common is it? A systematic review and meta-analysis of 14 studies of adults bereaved through non-violent deaths estimated a pooled prevalence of prolonged grief disorder of 9.8%, or roughly one in ten bereaved adults, with higher rates among older samples (Lundorff et al., 2017). Because that estimate excluded violent deaths, it may not reflect the experience of people bereaved by accidents, suicide or homicide. This distinction matters clinically: most grieving people do not need therapy, and grief itself should not be treated as an illness. A meta-analysis of 31 randomised controlled trials found that psychological interventions reduced grief symptoms by a small-to-moderate amount (g = 0.41 after treatment, g = 0.45 at follow-up), with a smaller effect once possible publication bias was taken into account (g = 0.31). Importantly, effects were larger when interventions were offered individually, to people who were at least six months past their loss, and to people selected because their grief symptoms were high (Johannsen et al., 2019). In other words, help works best when it is targeted at those who are genuinely stuck rather than offered routinely to everyone who is grieving.

Cognitive-Behavioural Therapy (CBT) for prolonged grief does not try to make people "get over" a loss or forget the person who died. Instead, it addresses the processes that can keep grief frozen in place. One is avoidance: steering clear of places, photos, conversations or memories connected with the death, which can prevent the loss from being emotionally processed. Exposure-based work gently helps the person tell and retell the story of the death and approach what has been avoided. Another process is unhelpful thinking, such as persistent self-blame ("I should have noticed the signs"), beliefs that life can never have meaning again, or that enjoying anything is a betrayal of the deceased. Cognitive restructuring helps examine these beliefs with compassion and balance. Behavioural activation supports a gradual return to valued activities and relationships, and many protocols also help people find a meaningful, continuing connection with the person who died.

Internet-based grief programmes typically translate these principles into a series of structured writing assignments, completed over several weeks, often with written feedback from a therapist after each task. A systematic review and meta-analysis of seven randomised trials with 1,257 bereaved adults found that all included web-based interventions were based on CBT, and that compared with control groups they produced moderate effects on grief symptoms (g = 0.54), large effects on post-traumatic stress symptoms (g = 0.86) and small effects on depression (g = 0.44), all of which remained stable over time (Wagner et al., 2020). A larger number of sessions was associated with greater improvement in grief, and more individual feedback with greater improvement in depression. An independent review of nine trials (1,349 participants) reached very similar estimates for grief (g = 0.54), depression (g = 0.44) and post-traumatic stress (g = 0.82), and reported high user satisfaction, although it graded the overall quality of evidence as low to moderate (Zuelke et al., 2021).

Individual trials show what this can look like in practice. In a randomised controlled trial with 87 people bereaved by cancer, a web-based CBT programme of structured writing tasks with asynchronous therapist support reduced prolonged grief symptoms to a clinically significant extent compared with a waiting list (Cohen's d = 0.80). Only 7% of participants dropped out, and the programme also improved depression, anxiety and post-traumatic stress, although it did not change sleep quality or physical health (Kaiser et al., 2022). For some bereaved people, writing privately at their own pace, at any hour, can feel more manageable than speaking about the loss face to face, and an online format can reach those who live far from specialised services or who are caring for others.

Where do apps and chatbots fit? Digital tools can offer psychoeducation about normal and prolonged grief, prompts for writing exercises, reminders to schedule meaningful activities and a space to notice patterns of avoidance or rumination. However, most of the evidence summarised above comes from programmes in which a human therapist read and responded to what participants wrote. Rigorous trials of fully automated conversational agents for grief are, to date, very limited, so their effectiveness for prolonged grief cannot yet be assumed. Grief is also deeply personal and shaped by culture, religion and family, and an automated tool may miss nuance that a trained clinician would notice.

There are further limitations to keep in mind. The number of trials remains small, many compare online CBT against a waiting list rather than against an active treatment, and samples have been modest (Wagner et al., 2020; Zuelke et al., 2021). Online grief programmes are not suitable for everyone. They are generally not indicated in the first weeks or months after a death, when intense grief is expected and usually eases with time and support. They are also not a substitute for specialised care for people bereaved by suicide, homicide or other traumatic deaths who have severe post-traumatic symptoms, for those with severe depression, substance misuse or thoughts of suicide, or for people who have little social support and feel overwhelmed.

It is worth seeking professional help if, many months after the loss, the yearning and pain remain as intense as in the beginning, if you are avoiding large parts of your life, if you feel that part of you died too, or if you are unable to work, look after yourself or relate to others. A general practitioner, psychologist or psychiatrist can assess whether prolonged grief, depression or PTSD is present and recommend appropriate treatment. Thoughts of wanting to join the person who died are not uncommon in grief, but if they turn into thoughts of ending your life, or you feel unable to keep yourself safe, contact your local emergency number immediately. Digital tools can complement, but do not replace, care from a qualified professional.

In summary, grief is a normal human experience, and most people do not need formal treatment. For the roughly one in ten adults who develop prolonged grief disorder, CBT-based interventions can help, and internet-delivered programmes, especially those that include therapist feedback, show moderate and lasting benefits in randomised trials. The evidence base is still growing, its quality is mixed, and evidence for fully automated tools is thin. Used thoughtfully, as part of a broader network of support, digital CBT can make help more accessible to bereaved people who are struggling to find their way forward.

References

  • Johannsen, M., Damholdt, M. F., Zachariae, R., Lundorff, M., Farver-Vestergaard, I., & O'Connor, M. (2019). Psychological interventions for grief in adults: A systematic review and meta-analysis of randomized controlled trials. Journal of Affective Disorders, 253, 69–86. https://doi.org/10.1016/j.jad.2019.04.065
  • Kaiser, J., Nagl, M., Hoffmann, R., Linde, K., & Kersting, A. (2022). Therapist-assisted web-based intervention for prolonged grief disorder after cancer bereavement: Randomized controlled trial. JMIR Mental Health, 9(2), e27642. https://doi.org/10.2196/27642
  • Lundorff, M., Holmgren, H., Zachariae, R., Farver-Vestergaard, I., & O'Connor, M. (2017). Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis. Journal of Affective Disorders, 212, 138–149. https://doi.org/10.1016/j.jad.2017.01.030
  • Prigerson, H. G., Boelen, P. A., Xu, J., Smith, K. V., & Maciejewski, P. K. (2021). Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World Psychiatry, 20(1), 96–106. https://doi.org/10.1002/wps.20823
  • Wagner, B., Rosenberg, N., Hofmann, L., & Maass, U. (2020). Web-based bereavement care: A systematic review and meta-analysis. Frontiers in Psychiatry, 11, 525. https://doi.org/10.3389/fpsyt.2020.00525
  • Zuelke, A. E., Luppa, M., Löbner, M., Pabst, A., Schlapke, C., Stein, J., & Riedel-Heller, S. G. (2021). Effectiveness and feasibility of internet-based interventions for grief after bereavement: Systematic review and meta-analysis. JMIR Mental Health, 8(12), e29661. https://doi.org/10.2196/29661