Prolonged Grief: When Grief Gets Stuck
A handout explaining prolonged grief: what it looks like when grief stays as intense and disabling as it was in the first weeks, why avoidance and rumination keep it stuck, and what helps. For adults a year or more past a loss who feel no movement.
About this resource
Most bereaved people find that, over months, acute grief gradually gives way to a quieter, integrated grief in which the loss is carried alongside a re-engaged life. For a minority, this does not happen. Prolonged grief disorder, recognised in ICD-11 and in DSM-5-TR, describes persistent intense yearning or preoccupation with the deceased, together with intense emotional pain, disbelief, avoidance of reminders, identity disruption and difficulty re-engaging with life, well beyond the period expected by the person's culture and context. The DSM-5-TR requires at least twelve months since the death for adults; ICD-11 uses at least six months.
The cognitive behavioural conceptualisation of Boelen, van den Hout and van den Bout proposes three maintaining processes: the loss has not been integrated into autobiographical memory, so it continues to feel unreal or recent; negative beliefs about the self, life and the future, and catastrophic interpretations of grief reactions, sustain distress; and avoidance, both of reminders and of the reality of the loss, together with rumination about why it happened and what could have been different, prevents processing. This handout translates that model into plain language and prepares the client for a treatment that will involve approaching the loss rather than skirting it.
The professional version adds notes on differentiating prolonged grief from major depression and PTSD, on the elevated suicide risk associated with prolonged grief, and on the components of evidence-based treatments such as Shear's complicated grief treatment.
How to use it
- Use this when a client is at least a year past a loss and describes grief that feels unchanged, with a life that has not restarted. Do not use it to pathologise ordinary grief in the first months.
- Assess for depression, PTSD (particularly after violent or sudden deaths) and suicidal thinking alongside grief. Prolonged grief and these conditions often co-occur.
- Walk through the section on avoidance and rumination with the client and ask them to identify their own versions. Write them down together.
- Explain that treatment involves revisiting the loss deliberately and rebuilding a life that includes it, and that this is uncomfortable but effective. Set expectations before starting exposure-based grief work.
- Consider a validated grief measure at baseline and at intervals to track change.
References
- Boelen, P. A., van den Hout, M. A., & van den Bout, J. (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109-128.
- Shear, M. K. (2015). Complicated grief. New England Journal of Medicine, 372(2), 153-160.
- Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., et al. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), e1000121.
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
