When Grief Won't End

Dadu Shin

C. S. Lewis wrote that after his wife died, it felt like there was an “invisible blanket” between him and the world. “I not only live each endless day in grief, but live each day thinking about living each day in grief,” he said. “Her absence is like the sky, spread over everything.”

For most bereaved people, including Lewis, who chronicled his suffering in his 1961 book A Grief Observed, this type of all-consuming, debilitating pain eventually fades. But for those with “prolonged grief disorder,” an enigmatic condition that afflicts 7 to 10 percent of bereaved adults, time does not heal. Instead their anguish may persist, raw and unresolved, for years or even decades.

Katherine Shear, a psychiatrist at the School of Social Work and the founder of Columbia’s Center for Complicated Grief, is a pioneer in describing, diagnosing, and treating prolonged grief disorder (which is also known as complicated grief). Shear was instrumental in getting prolonged grief disorder included in psychiatry’s diagnostic bible, the DSM-5, this year but she notes that many clinicians are still unaware of the condition. “Even if you go to a really good psychologist, there’s less than a 50–50 chance that prolonged grief disorder will be properly recognized,” she says.

Although people with a history of depression and anxiety are thought to be at a greater risk for prolonged grief disorder, anyone can be afflicted. People who lose a loved one suddenly — such as in an unexpected medical emergency, a car crash, a violent crime, or in the line of duty — are particularly vulnerable. Shear expects that the COVID-19 pandemic will cause an increase in cases of complicated grief. “So many people are being lost quickly and unexpectedly, without the opportunity for final visits or goodbyes,” she says. “Additionally, bereaved people may be dealing with anxieties related to job security, child-rearing, the loss of routine activities, and worries about their own health and that of their surviving family members. This kind of background stress adds to the challenge of adapting to a loss.”

The key to coping with a loved one’s death, Shear says, is to fully accept the reality of the situation. But people with prolonged grief disorder struggle to do this. Instead, they may get caught up in imagining alternative scenarios in which their loved one’s death is averted — “If only he’d visited a doctor one month earlier” — and thus delay their own healing. “To engage in this kind of counterfactual thinking is common after any important loss,” Shear says. “But while most people will eventually say, ‘OK, well, although I wish this hadn’t happened, it did happen, and now I have to figure out a way to live with the fact,’ those with prolonged grief disorder will get stuck there. They can’t move forward in a positive way.”

Other common symptoms of prolonged grief disorder include a tendency to blame oneself or others for a loved one’s death; excessive avoidance of places or situations that remind one of the deceased; survivor’s guilt; and social withdrawal.

In the 1990s, Shear developed a sixteen-session treatment program that is now called “Prolonged Grief Disorder Therapy,” or PGDT. The program’s efficacy has been demonstrated in multiple clinical trials, and PGDT is now the most widely used treatment for the condition. Combining elements of cognitive behavioral therapy, interpersonal psychotherapy, and motivational interviewing, it consists of a series of activities in which patients reflect on their grief; visit places that remind them of their loss; explore possibilities for their own future; strengthen their relationships with other family members and friends; and have an imaginary conversation with the deceased in which they acknowledge their need to move forward. “It’s intense,” Shear says. “But we’ve found that with this therapy, people who have struggled for years come out on the other side and are able to reengage in life in a meaningful way after just four months.”

In an effort to make PGDT more widely accessible, Shear and her colleagues at the Center for Complicated Grief have organized trainings on how to administer the therapy for thousands of practitioners around the world. They have also developed a mobile app that enables patients to receive an abbreviated version of PGDT online.

As the US death toll from COVID-19 continues to grow, it is sobering to consider the huge numbers of grieving husbands, wives, fathers, mothers, sons, daughters, grandsons, and granddaughters who have been left behind. One team of sociologists estimates that each person who dies from COVID-19 leaves an average of nine bereaved family members, which means that millions of Americans have lost an immediate family member to the disease. “There’s a great sense of urgency now to make sure that health and mental-health providers are able to recognize and treat prolonged grief disorder, ” says Shear. “We have to be ready to help these people.”

Read more from