Living with loss: a cognitive approach to prolonged grief disorder – incorporating complicated, enduring and traumatic grief

In cognitive behavioural journals and scientific meetings, the subject of grief seems to receive less attention than other emotional states, such as anxiety or depression. Grief is recognised as a normal human reaction to the death of a loved one and incorporates unpleasant, potentially distressing emotions, psychological phenomena, such as intrusive images, and physical sensations. Understandably, there has been reluctance to pathologise grief responses. However, the COVID-19 pandemic has put the subject of death centre stage as millions of people worldwide have been bereaved in extraordinary circumstances. Psychological therapists have been asked to provide effective therapeutic responses for clients with enduring distressing grief reactions.In this paper, we draw on decades of research and clinical expertise from our experience in applying cognitive therapy for post-traumatic stress disorder (PTSD) to enduring grief reactions. We derive lessons learned for treating prolonged and traumatic bereavement. Many of the clinical trials at the Oxford Centre for Anxiety Disorders and Trauma and Omagh/Queen’s University Belfast trauma centres have included patients who have experienced significant traumatic loss (Duffy et al., 2007; Ehlers et al., 2014; Ehlers et al., 2022).During the pandemic the authors of this paper delivered several workshops on prolonged and traumatic grief where clinicians raised a number of thought-provoking questions. Our responses form the basis of this paper.(1)How do we differentiate between normal and abnormal or pathological grief?(2)How should we describe or categorise or label pathological grief, and is it a specific and distinct condition or disorder?(3)How effective are existing therapies for prolonged and traumatic grief and is there a role for CBT in the treatment of these conditions?(4)Can our experiences with cognitive therapy for PTSD (Ehlers et al., 2005) help with these conditions or are different techniques and skills required?The purpose of this paper is to answer these important questions and in so doing, consider the historical and theoretical concepts relating to complex and traumatic grief; factors that differentiate normal grief from abnormal grief; and maintenance factors as well as implications for CBT treatments.