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. For people experiencing loss, cognitive behavioral therapy (CBT) can effectively improve symptoms. 

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

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, 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 posttraumatic stress disorder (PTSD).  

If you are experiencing suicidal thoughts or urges, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text 988 to talk to someone over SMS. Support is available 24/7.

If you are experiencing trauma, support is available. Please see our Get Help Now page for more resources.

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 grief

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. 

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 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. 

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, CBT focuses on coping with specific, current challenges 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.  

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. 

Building awareness

In this stage, your therapist can help you develop an awareness of your automatic thoughts 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 have an awareness of your unhelpful thoughts, you may notice how they negatively affect your emotional and physical well-being. Through cognitive restructuring, a therapist can help you interrupt these 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 posttraumatic stress disorder (PTSD). 

Can online CBT help?

Some people who are grieving experience debilitating symptoms like depression and extreme fatigue. If the prospect of 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 who specialize in grief counseling. Plus, you can use in-app messaging to reach out to your therapist whenever you need some 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 post-traumatic stress disorder. 

One proposed study aims to evaluate online grief-specific CBT for persistent complex bereavement disorder, posttraumatic stress disorder, 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.