Complicated or prolonged grief treatment

1. Introduction

Version followed: M. Katherine Shear's 16-session Prolonged Grief Disorder Therapy (PGDT; earlier called Complicated Grief Treatment, CGT; some current Columbia materials say PGT), as taught in the Columbia Center for Prolonged Grief Practice-Focused Training slides (Day 2 deck dated 2022, Day 1 deck dated March 2023), with phase and session names from the 2015 CGT instruction manual (only its preview is drawn on). The earlier 1998–99 "traumatic grief treatment" pilot manual (14–18 sessions of 60–90 minutes) is cited only where it adds detail, and is marked as such. Boelen's CBT for prolonged grief and Rosner's PG-CBT are separate protocols and are not covered here. [source: Columbia PFT Day 1 and Day 2 slides; CGT Manual Bundle preview; Harkness et al. 2002]

PGDT is a time-limited, structured individual psychotherapy for people who meet criteria for prolonged grief disorder (DSM-5-TR: death at least 12 months ago; ICD-11: at least 6 months). Its view of change is this. Grief is natural and permanent, "the form love takes when someone we love dies" (Day 2 slides). Adapting to a loss has two tasks: accepting that the death is real and final, and regaining the capacity to thrive. Adaptation usually moves from acute grief to integrated grief on its own. In prolonged grief it is stalled by "derailers": thoughts (self-blame, "if only" counterfactuals, second-guessing), feelings (dysregulated pain, little positive emotion) and behaviours (avoiding reminders, escape, health-harming habits). Treatment removes these impediments and does not try to end grief. Each session pairs loss-focused work (revisiting the death and its reminders) with restoration-focused work (goals, relationships, rewarding activities), organised around seven "healing milestones". The procedures borrow from prolonged exposure for PTSD, interpersonal psychotherapy (IPT) and motivational interviewing (MI). [source: Day 1 and Day 2 slides; Shear in Carlat Report 2023]

2. Framework

Format. Individual, 16 weekly sessions over about 4–5 months. One session (session 3) includes a visitor the client chooses. Between sessions the client keeps a daily grief monitoring diary, listens to the recorded revisiting, does situational revisiting and fills in interval plans. Session length is not stated in the current slides or in the Carlat interview. The 1998–99 pilot used 60–90-minute sessions, and revisiting sessions plausibly need longer than a standard hour, given about 30 minutes of revisiting steps plus diary review and restoration work. [source: Day 1 slides; Harkness et al. 2002] [uncertain: session length in the current version]

Seven healing milestones (each paired with a procedure; the Carlat table lists six because it merges the first two):

Understand and accept grief → psychoeducation, grief monitoring.
Manage emotions → grief monitoring, rewarding activities, self-compassion, setting the story aside.
See a promising future → aspirational goals, rewarding activities.
Strengthen relationships → session with a visitor, ongoing attention to contact and support.
Narrate the story of the death → imaginal revisiting.
Learn to live with reminders → situational revisiting.
Connect with memories of the person who died → memories questionnaires, pictures, imaginal conversation. [source: Day 1 and Day 2 slides; Carlat 2023 Six Milestones table]

Standard session structure (sessions 4 onward): (1) set the agenda; review the grief monitoring diary and last week's plans. (2) Loss focus: the story of the death or reminders. (3) Restoration focus: aspirational goals and rewarding activities. (4) Close: highlights, feedback, interval plans for the week. Emotional activation is meant to fall over the course of each session. [source: Day 2 slides; Day 1 slides]

Phases and sessions (2015 manual phase names; contents from 2022–23 slides):

Pre-treatment fit check. Is grief the main problem, and does it meet PGD criteria? Is another disorder primary? Does a co-occurring condition need treatment first? The slides list psychotic disorder, bipolar disorder, substance use disorder and imminent suicide risk. Screen with the Brief Grief Questionnaire (5 items) or the Inventory of Complicated Grief (19 items; above 30 = positive). Characterise further with the Typical Beliefs Questionnaire (TBQ), the Grief-Related Avoidance Questionnaire (GRAQ), the Structured Clinical Interview for PGD and the Work and Social Adjustment Scale (WSAS). [source: Day 1 slides]
Phase I: Getting started (sessions 1–3). S1: history taking (life, relationships, the loss, the story of the death, current functioning); introduce grief monitoring. Between S1 and S2 the therapist writes a case formulation. S2: formal psychoeducation about grief, PGD and PGDT; introduce aspirational goals; plan whom to invite. S3: session with a visitor. Goals: engagement and alliance, a shared formulation, belief that treatment is promising, and agreement to do the activating procedures. [source: Day 1 and Day 2 slides; Manual preview]
Phase II: Core revisiting sequence (sessions 4–9). S4: first imaginal revisiting. S5: imaginal revisiting plus introduction of situational revisiting. S6: revisiting plus the first memories questionnaire. S7–9: "full core revisiting": imaginal and situational revisiting, memories work and goals each session. Imaginal revisiting is repeated over 3–6 sessions. Goals: tell the story of the death, reduce avoidance, regain access to memories. [source: Manual preview; Day 1 and Day 2 slides]
Phase III: Midcourse review (session 10). Re-administer the ICG, TBQ and GRAQ and compare with baseline. Review progress, expectations, each procedure, the visitor relationship and what remains; plan the last six sessions. [source: Day 2 slides; Manual preview]
Phase IV: Closing sequence (sessions 11–16). S11: imaginal conversation, and ending is raised. S11–15: personalised work to finish the milestones (more memories work, situational revisiting, goals, difficult-times planning). S16: ending. Termination goes on the agenda four sessions before the end and gets more time each session. [source: Day 1 and Day 2 slides; Manual preview] (The Day 2 slides place memories work from about session 9 after progress in accepting the death; the Day 1 session map places the first memories questionnaire at session 6. Follow the session map, and pace memories work by readiness.) [uncertain: minor sequencing discrepancy between decks]

Criteria for moving on (the slides give a fixed session map; these are the readiness signals they name):

Into imaginal revisiting (S4): alliance in place, rationale understood, client agrees to the activating procedures, visitor session done. [source: Day 1 and Day 2 slides]
Repeat imaginal revisiting until: activation falls within and across tellings; the narrative becomes more coherent; derailers have surfaced and been worked on; the client shows a felt acceptance that the death happened. Then imaginal revisiting can be reduced or stopped and situational revisiting carries on. [source: Day 2 slides]
Into memories work and imaginal conversation: progress in accepting the reality of the death. [source: Day 2 slides]
Into ending: a midcourse review with remaining goals set; termination added four sessions before the last. If the client may not be ready (insufficient progress, risk of backsliding, cannot manage without weekly contact, other problems), decide jointly whether further work is needed. [source: Day 2 slides]

3. Guiding principles

Grief is a form of love that finds a place in life (Day 1 premise). → Never aim to eliminate grief or to have the client "let go"; aim for grief that is integrated and coexists with a satisfying life. [source: Day 1 slides]
Adaptation progresses naturally if not impeded. → Your job is to find and remove derailers, not to install a new grieving process; ask "what is getting in the way?" [source: Day 1 slides]
Everyone grieves and adapts in their own way. → No stages, no expected grief levels or timetable; follow the client's way of grieving and their cultural norms. [source: Day 1 slides]
We don't grieve well alone. → Actively strengthen relationships (visitor session, encouraging a companion for situational revisiting, watching for isolation). [source: Day 1 and Day 2 slides]
Accepting grief means not trying to lower it. → When reviewing the diary, hold no expectations about the numbers; praise observation, not low scores. [source: Day 1 slides]
Active listening, unconditional acceptance, no judgment, willingness to share the pain. → This is the base of every session; the procedures sit on top of empathy, support and validation. [source: Day 1 slides; Carlat 2023]
Listening alone is not enough. → Keep each session focused on promoting adaptation and targeting derailers, using the structured procedures, rather than supportive listening only. [source: Day 1 slides]
Clients find their own way; the therapist validates, supports and guides. → Favour self-observation and self-determination; do not supply answers or give unsolicited advice. [source: Day 1 and Day 2 slides]
Collaborate with elicit–provide–elicit. → Ask what the client already understands, ask permission, give information in small plain pieces, check understanding, watch non-verbal cues, use metaphor, pace yourself. [source: Day 1 slides]
Pair loss focus with restoration focus, and end lower than you started. → Every revisiting session ends with setting the story aside and a rewarding activity; never end on peak activation. [source: Day 2 slides]
The hard part comes last, introduced gradually. → Milestones are introduced in sequence; explain the rationale for the painful procedures early and introduce them step by step. [source: Day 1 slides; Carlat 2023]
Structure regulates emotion. → A predictable ritual, a time limit and distress ratings make the activating work safe; keep to them. [source: Day 2 slides]
Positive emotion is a resource, not a betrayal. → Prescribe rewarding activities and address survivor guilt when pleasure appears. [source: Day 2 slides; Carlat 2023]
Goals must be intrinsically motivated (self-determination theory: autonomy, competence, relatedness). → Elicit what the client wants, not what others expect; achieving goals during treatment is not required. [source: Day 1 slides; Carlat 2023]
Self-compassion lowers painful emotion. → Notice and gently correct self-judgment; frame suffering and mistakes as shared human experience. [source: Day 2 slides]
Do not offer comfort or "it could have been worse" reassurance during the work. → Shear says such downward comparisons usually backfire; during the telling, bear witness rather than relieve. [source: Carlat 2023; Day 2 slides]
Know your own responses to loss. → Expect the work to be painful and to stir your own fears about death; deal with these (supervision, consultation) so you do not steer clients away from pain. [source: Day 1 slides; Carlat 2023]
Measurement-based care. → Track grief with the diary each session and formal measures at baseline, midcourse and end. [source: Day 2 slides; Manual preview (preface heading)]

4. Intervention inventory

The 2015 manual's appendix lists these forms: Interval Notes, Interval Plans, Grief Monitoring Diary, between-session imaginal and situational revisiting forms, Memories Forms 1–5, a Difficult Times form, a case formulation worksheet, a therapist Imaginal Revisiting form, a Situational Revisiting List, and patient and family handouts. Their contents were not available. Make your own simple equivalents (described below) or buy the manual from Columbia. Do not reproduce Columbia's forms. [source: Manual preview]

4.1 Intake, history taking and case formulation (session 1)

Purpose: engagement as much as fact-finding. Confirm PGD; find strengths, supports and derailers; decide whether grief is the most pressing problem. [source: Day 1 slides]
Steps:
1. Before or at intake, screen (BGQ or ICG) and rule out conditions that need treatment first (psychosis, bipolar disorder, substance use disorder, imminent suicide risk). Assess co-occurring depression and PTSD and decide which is primary. Differentiators in the slides: yearning versus pervasive low mood; waves of pain versus persistent low mood; guilt about caregiving or surviving versus worthlessness; suicidal thoughts about joining the deceased or not living without them; for PTSD, loss and yearning versus threat and fear. [source: Day 1 slides]
2. Take a life history: early relationships, education and work, interests, values, religious or spiritual beliefs, racial identity and experiences of systemic or racial maltreatment, stressors, strengths and supports. [source: Day 1 slides]
3. Explore the relationship with the deceased.
4. Ask about the death. This is the harder conversation, so pace it. Ask where and how the client learned of it and what happened next. Listen for derailers (protest, blame, "if only") without challenging them yet. [source: Day 1 slides]
5. Ask open questions about daily life now: how time is spent, with whom, and what has changed since the death.
6. Introduce the grief monitoring diary (4.3).
7. Between sessions, complete a formulation: facts of the death; PGD symptoms and derailers; personal history (vulnerabilities, strengths); current context (finances, WSAS, supportive and unsupportive relationships). [source: Day 1 slides]
Example language (illustrative): "I'd like to understand your life as well as your loss, so we'll cover quite a lot today. When it comes to how she died, take it at whatever pace feels right. Where were you when you found out?"
Watch for: suicidal thoughts framed as wanting to be with the deceased or a sense of not being fully present; Shear advises probing for these when identity disruption appears. Also watch for heavy alcohol use, and for a primary disorder that would make PGDT premature. [source: Carlat 2023; Day 1 slides] It is working if the client leaves feeling understood and willing to return.

4.2 Session agenda and interval plans (every session)

Purpose: a predictable structure that contains emotion and keeps both loss and restoration in each session. [source: Day 2 slides]
Steps: (1) Set the agenda together. (2) Review the diary, then the previous interval plans (listening, situational revisiting, goals, rewarding activities). (3) Do the loss-focused procedure. (4) Do the restoration-focused work. (5) Ask the client for highlights of the session and feedback. (6) Write interval plans for the coming week. [source: Day 2 slides]
Example language (illustrative): "Before we finish, what stood out for you today? Let's write down the plan for this week: listening each morning, the café on Thursday, and something just for you on Saturday."
Watch for: sessions that slide into unstructured support ("listening alone is not enough"). Plans should be specific and agreed, not imposed.

4.3 Grief monitoring diary (from session 1, throughout)

Purpose: help the client observe their grief, see that it rises and falls, and find activators and derailers. Milestones: understanding grief, managing emotions. [source: Day 1 and Day 2 slides]
Steps:
1. Explain the purpose: getting to know one's grief, not grading it.
2. The client records each day: the highest grief level with a note on what was happening; the lowest level with a note; and an overall rating for the day. The slides vary between 0–10 and 1–10 scales, so choose one and keep to it. [source: Day 1 slides] [uncertain: exact scale]
3. At the start of each session, review briefly. Comment on one high and one low for the week, then wait for the client or ask an open question. [source: Day 1 slides]
4. For highs, explore what was happening, thoughts, feelings, behaviour, and whether the client accepted the grief and let it pass or fought it and was overtaken. Look for activators, hidden avoidance, and support or coping options. For lows, explore what helped (distraction, rewarding activities, interests) and what made the low hard to keep (survivor guilt, feeling that low grief betrays the deceased). Use the overall ratings to talk about adaptation over weeks. [source: Day 1 and Day 2 slides]
Example language (illustrative): "I see Tuesday was a 9 around six o'clock, and Saturday got down to a 3. What was going on Tuesday evening?" … "And on Saturday, how did it feel to have a lighter moment?"
Watch for: derailers at highs (judging or controlling grief, shame, protesting or revising the death, escaping triggers). At lows, watch for survivor guilt and for treating low grief as betrayal. Watch for extremes recorded with no notes, or a diary filled in just before the session. It is working when the client can describe their grief, predict activators, and accept the swings. [source: Day 1 slides]

4.4 Psychoeducation (formal in session 2, then as needed)

Purpose: non-judgmental information that builds motivation, respect for strengths and hope, and agreement on goals and procedures. [source: Day 1 slides]
Steps: prepare from the formulation. Cover five topics using elicit–provide–elicit: (1) close relationships, and grief as a form of love; (2) grief as a stress response, including secondary stressors such as role loss, family strain and invitations drying up, and its effects on body and mind; (3) adaptation, its two tasks, acute versus integrated grief, and the milestones; (4) pause points and derailers; (5) PGD and how PGDT works. Explain attachment, caregiving and exploration, and how loss activates the first two and inhibits the third. Name what helps adaptation: managing emotion, positive emotion, support, effective daily coping. Describe every procedure, saying plainly that two are emotionally activating (imaginal and situational revisiting), and offer examples if the client wants them. Frame the problem as difficulty adapting, not grief itself. [source: Day 1 slides; Carlat 2023] Give a written handout (Columbia supplies short patient and family handouts with the manual). [source: Manual preview]
Example language (illustrative): "Grief isn't something we want to get rid of. It's how love continues after a death. What seems to have happened is that some natural reactions, like going over what could have been done differently, have got stuck and are keeping the grief raw. This treatment works on those."
Watch for: shame ("something is wrong with me"), fear that treatment means forgetting, scepticism about revisiting. Check understanding after each piece. It is working when the client can say the model back in their own words and agrees to try.

4.5 Aspirational goals (from session 2, throughout)

Purpose: restore a sense of a promising future and re-activate exploration (milestone 3). Guided by self-determination theory and a modified MI goal-setting approach. [source: Day 1 slides; Carlat 2023]
Steps:
1. Ask a "magic wand" question: if grief were at a manageable level, what would the client want for themselves? [source: Day 1 slides]
2. Acknowledge that they are not there yet.
3. Follow up: what might get in the way, who could help, how they would know they were working towards it, how committed they feel now. [source: Day 1 slides]
4. When a goal emerges, use MI to plan a small, specific project with next steps, and add it to the interval plans. [source: Day 1 slides]
5. Revisit every session in the restoration segment. Achieving the goal during treatment is not expected. [source: Day 1 slides]
6. If the client is stuck, ask about childhood dreams and what used to be fun, discuss what others pursue, brainstorm, do a values card sort, use an aspirational-goals questionnaire, or take an occupational-counselling approach. [source: Day 1 slides]
Example language (illustrative): "Suppose you woke up tomorrow and the grief had settled into something you could carry. Not gone, but manageable. What would you want for yourself then?"
Watch for: goals that are what others expect (check that it is intrinsic: "Is this something you want, or something you feel you should want?"); irritation or "I can't want anything", which is often protest about the injustice of the death (a derailer to explore, not argue with). It is working when energy and talk of the future increase. Even discussing values can raise hope. [source: Day 1 slides]

4.6 Rewarding activities and daily self-care (throughout)

Purpose: balance pain with positive emotion; positive emotion supports coping, health and social resources. [source: Day 1 and Day 2 slides]
Steps: the client lists small pleasures; plans one rewarding activity for the week; builds a small daily ritual of something enjoyable or restorative; after every imaginal revisiting, commits to a rewarding activity for that same day (4.9 step 4). Review in each session. Also review sleep, nutrition, health care and alcohol, since health-harming behaviour is a derailer. [source: Day 1 and Day 2 slides]
Example language (illustrative): "What's one small thing you used to enjoy, even for ten minutes? Could that be part of each day this week?"
Watch for: survivor guilt or the sense that enjoyment is disloyal. Address it directly rather than dropping the activity. [source: Carlat 2023] It is working when energy and enthusiasm rise and pleasure is tolerated. [source: Day 1 slides]

4.7 Self-compassion work (as needed, especially with guilt and self-blame)

Purpose: reduce the intensity of painful emotion and counter self-judgment, a frequent hidden derailer. [source: Day 2 slides]
Steps: help the client notice self-critical thoughts (in the diary, in reflection after revisiting). Invite them to respond as they would to a friend in the same position. Point to the shared human experience of suffering and mistakes. Encourage mindful observation of thoughts and feelings without getting caught up in them. Separate what can still be changed (focus effort there) from what cannot (work towards acceptance). [source: Day 2 slides]
Example language (illustrative): "If your sister had been the one at the hospital that night and made the same call, what would you say to her?"
Watch for: the client dismissing self-kindness as making excuses. Frame it as accurate, not lenient. [synthesis] It is working when self-blame statements soften in reflection and diary notes.

4.8 Session with a visitor (session 3)

Purpose: strengthen relationships (milestone 4); enlist support; let someone close witness the client's pain without fixing it. [source: Day 2 slides; Carlat 2023]
Steps:
1. In session 2, ask whom the client would like to invite. Ideally this is someone who knew the deceased well and has tried to help, such as a close family member or someone they live with, but anyone the client is willing to bring will do. [source: Day 2 slides]
2. In session 3, cover four goals: (a) the visitor's relationship with the client; (b) the visitor's view of the deceased and of the client's life since the death; (c) an overview of PGD and PGDT; (d) how friends and family can support the client. [source: Day 2 slides]
3. Give information, help set goals, suggest concrete support strategies. Explain the revisiting procedures and their rationale so the visitor will not undermine them. The pilot authors stressed explaining exposure fully to families. [source: Day 2 slides; Harkness et al. 2002]
4. Throughout treatment, notice increases in contact and comfort with significant others. [source: Day 2 slides]
Example language (illustrative): "You've watched Maria go through this for two years. What has it been like for you? … What do you think has helped her, and what hasn't?"
Watch for: a visitor who fears the treatment is cruel (see 5.4); a visitor whose own grief dominates; a client who says no one can come (see 5.3). It is working when the client and visitor leave with shared understanding and a specific support plan.

4.9 Imaginal revisiting: telling the story of the death (sessions 4–9, repeated over 3–6 sessions)

Purpose: make the reality of the death felt, reduce the avoidance and protest around it, and bring out derailers such as self-blame and counterfactual thinking (milestone 5). Modelled on prolonged exposure for PTSD. [source: Day 2 slides; Carlat 2023]
Before the first telling (safety and consent): the client has had the rationale (S2), agrees to the procedure, and knows it will be painful and is time-limited. Imminent suicide risk, active psychosis, mania and unstable substance use have been addressed first. Arrange recording, and book a phone check-in for the first day of home listening. Explain that the client can open their eyes or pause at any time. [source: Day 1 and Day 2 slides] [synthesis: the stop/pause permission and the explicit consent check as written here]
Steps (four timed steps; about 25–30 minutes in total) [source: Day 2 slides]:
1. Telling (about 10 min). Ask for a distress rating (0–100 SUDS-type, equivalent to a grief level). Start recording. The client closes their eyes, pictures the moment they first learned of the death, and tells what happened from there in the present tense, in whatever form they choose the first time. Ask for a rating periodically. The pilot version asked about every 5 minutes. [source: Day 2 slides; Harkness et al. 2002] Your role: listen closely, bear witness, give brief encouragement for effort, gently prompt the client to continue. Do not guide, comfort, suggest, or try to relieve the pain during the telling. [source: Day 2 slides]
2. Reflection (about 10 min). The client opens their eyes and gives a rating. Briefly validate the effort. Ask what it was like to tell the story and what they noticed, and repeat as needed. Listen actively for derailers (self-blame, anger at others, "if only") and for signs of the milestones, and validate, support or guide as needed. Do not add your own observations, steer to your own topic, or try to fix thoughts and feelings. [source: Day 2 slides] Shear describes this step as the point where self-blame and counterfactual thinking come up to be worked on. [source: Carlat 2023]
3. Setting the story aside (2–5 min). Take a rating. Invite the client to put the story away, knowing they will come back to it daily this week. Use a short visualisation or grounding exercise if they need help. [source: Day 2 slides]
4. Planning a reward (2–5 min). The client commits to a specific rewarding activity after the session that day. [source: Day 2 slides]
Later sessions: review the week's listening and the ratings. Repeat the telling from the same starting point. The pilot version moved later tellings to "hot spots", the highest-distress parts of the story. That is not described in the current slides, so use it as an option rather than as the protocol. [source: Day 2 slides; Harkness et al. 2002] [uncertain: whether the current version focuses on hot spots]
Example language (illustrative): "Close your eyes and go back to the moment you heard. Where are you? Tell it as if it is happening now … What's your number right now? … You're doing well; stay with it … What happens next?" Then: "Open your eyes when you're ready. What was that like?" Then: "Let's put the story away for now. You can picture closing it in a box if that helps. What will you do for yourself when you leave here today?"
Watch for: across sessions, falling peak and end ratings, a more coherent story, derailers that can be named and worked on, and a shift towards felt acceptance ("it really happened"). These are the signs it is working. [source: Day 2 slides] Red flags: dissociation, trouble setting the story aside, ratings that stay high, the client stopping listening (see 5.5). In the pilot, 3 of 35 patients dropped out because they could not tolerate the exposure. Rationale and support therefore matter. [source: Harkness et al. 2002]

4.10 Home listening to the recorded telling (between sessions, during the revisiting weeks)

Purpose: extend revisiting into daily life and practise moving into and out of the story. [source: Day 2 slides]
Steps: agree on daily listening, preferably in the morning, so the day can then move on. Before, at the peak of, and after each listening, the client records a distress rating on a simple form. Phone the client on the first day of listening. Follow each listening with an ordinary or rewarding activity. Review the ratings in the next session. [source: Day 2 slides] [synthesis: follow with an activity, extending the in-session step 4]
Example language (illustrative): "Mornings work best for most people, so the rest of the day can carry on. Write your number before, the highest point, and after. I'll call you on Wednesday to see how the first one went."
Watch for: skipped listening (avoidance, or feeling overwhelmed), and listening at night followed by rumination. It is working when ratings fall within and across listenings. [source: Day 2 slides; Harkness et al. 2002]

4.11 Working with derailers in reflection and diary review (throughout)

Purpose: loosen the thoughts, feelings and behaviours that block adaptation. Derailers by milestone, per the slides: wanting to hold on to or get rid of grief; fear of pain and rejecting positive emotion; discomfort with happiness; inability to accept support; protest, blame and "if only" rewriting of the death; avoiding reminders; daydreaming about or blocking memories. [source: Day 1 slides]
Steps: (1) Notice the derailer as the client voices it (for example "I should have insisted on the second opinion", "Grief is all I have left of him"). (2) Reflect it back and ask how it affects their grief and life. (3) Explore it with open questions and self-observation, not argument. Examples: what they knew at the time; what they would say to someone else; what holding on to it protects. (4) Bring in self-compassion (4.7) and the facts that came out in revisiting. (5) Link the work to a milestone and to the interval plan. [source: Day 1 and Day 2 slides] [synthesis: the specific step order and the questions; the slides list derailers and say to address them but give no scripted method]
Example language (illustrative): "You've said 'if only I'd called earlier' a few times. When you go over that, what happens to the grief? … What did you actually know at 9 p.m. that night?"
Watch for: debating the client. The aim is self-observation and acceptance, not winning a cognitive dispute. It is working when "if only" statements decrease and the client spontaneously reframes.

4.12 Situational revisiting: living with reminders (from session 5)

Purpose: reduce avoidance of grief-triggering people, places, activities and objects. Avoidance blocks learning that the death is final and is a major source of impairment. Situational revisiting also releases positive memories, makes room for bittersweet pleasure and reduces survivor guilt (milestone 6). [source: Day 2 slides; Carlat 2023]
Steps:
1. Discuss avoidance: what the client avoids, why, and what it costs. Explain the exercise as like in vivo exposure for phobias. Get agreement. [source: Day 2 slides]
2. The client lists reminders, for example the cemetery, letters, the person's room, a holiday party, a shop they used to visit together, and rates the grief intensity they expect from each. [source: Day 2 slides; Carlat 2023]
3. Choose a first target that is "challenging but doable" (Day 2 slides). Start with something the client is motivated to do, or with a necessary task (for example, medical visits at the hospital where the person died). [source: Day 2 slides]
4. Practise it, ideally daily, over the coming week. Encourage the client to bring a supportive companion. Invite them to notice positive memories as well as pain. [source: Day 2 slides]
5. On a form, the client records ratings before, during (peak) and after each practice. [source: Day 2 slides]
6. Each session: was it done? Review the ratings. Rate the experience (good, very good, not so good). Choose the next item, typically weekly. [source: Day 2 slides]
7. Continue after therapy ends. [source: Day 2 slides]
Less formal alternative: discuss avoidance in conversation and help the client plan a meaningful activity, such as honouring the deceased, doing something enjoyable, or reconnecting with family and friends. Use this when a formal hierarchy feels too mechanical for the client. [source: Day 2 slides]
Example language (illustrative): "Of everything on your list, which one would be hard but feel doable this week? … Would your brother come with you? While you're there, notice any good memories that come up too."
Safety: remove real-world hazards from the plan. For example, don't schedule driving immediately after a very activating visit. Avoid items whose distress is from threat rather than loss until PTSD has been assessed. [synthesis]
Watch for: all-or-nothing jumps to top items, and stopping after a bad experience (see 5.6); "everything is 100" (see 5.7); safety behaviours such as rushing through. It is working when ratings fall, more places and objects come back into use, and positive memories emerge. [source: Day 2 slides]

4.13 Memories questionnaires (from session 6, or once acceptance is progressing, through to the end)

Purpose: restore access to a full, balanced and comforting set of memories of the person, so the relationship continues in memory (milestone 7). The pilot authors added this so that patients could remember the deceased "in a more comforting way". [source: Day 2 slides; Harkness et al. 2002]
Steps: give one memories form as homework, then review it in the next session. Over successive weeks, work through four question sets the slides describe (the 2015 manual has five forms, "Memories Forms 1–5", whose fifth was not seen): (1) positive memories: likeable traits, enjoyable times, things they loved, what they added to the client's life, favourite pictures; (2) most-favourite memories: their best traits, what the client loved and misses most, how the client comforts themselves; (3) least-favourite memories: annoying traits, what the client wished had been different, what is not missed, ways life is easier now; (4) mixed memories: both sides together, admiration, missing most and least, self-comfort. Write your own prompts covering these themes; do not copy Columbia's forms. [source: Day 2 slides; Manual preview] [uncertain: content of form 5 and the exact order; the slides do not fix a strict sequence]
Example language (illustrative): "This week, write down some good memories: things he did that made you laugh, times you enjoyed together. Next we'll also look at the parts that were harder, because a real person has both."
Watch for: idealisation, and difficulty writing anything negative (guilt). Watch for daydreaming used to escape. It is working when the client tells stories more freely, smiles while remembering, and holds a mixed, realistic picture. [source: Day 1 and Day 2 slides]

4.14 Bringing a favourite picture

Purpose: gently counter avoidance of photographs and reconnect the client with positive memories. [source: Carlat 2023]
Steps: ask the client to bring a favourite photo of the person to a session. Ask about it: who took it, what was happening, what it shows about the person. Let the stories come. [source: Carlat 2023] [synthesis: the specific questions]
Example language (illustrative): "Would you bring in a photo of her you love? I'd like to meet her a little."
Watch for: Shear notes that many clients avoid photos, especially the last one taken before the death, but often start smiling and telling stories once they share a favourite. That shift is the sign it is working. [source: Carlat 2023]

4.15 Imaginal conversation with the person who died (session 11, can repeat)

Purpose: create a strong sense of connection with the deceased, and revisit troubling thoughts and feelings such as unsaid words, guilt and unanswered questions (milestone 7). [source: Day 2 slides; Carlat 2023]
Prerequisites: progress in accepting the death; imaginal revisiting is well established. [source: Day 2 slides]
Steps [source: Day 2 slides; Carlat 2023]:
1. Explain the procedure and answer questions. Take a distress rating.
2. The client closes their eyes and imagines being with the person shortly after the death, able to speak to them and be heard.
3. The client says or asks whatever they wish.
4. The client then takes the role of the deceased and answers. The client may switch between speaking as themselves and as the deceased.
5. Keep it to 10–15 minutes. Help only to clarify the procedure.
6. Take a rating at the end. Spend about 10 minutes reflecting on the experience.
7. Close as for revisiting: set the experience aside and plan something rewarding. [synthesis: carrying steps 3–4 over from imaginal revisiting]
Example language (illustrative): "Close your eyes. Imagine he's here with you, just after he died, and he can hear you. What do you want to say to him? … Now be him for a moment. What does he say back?"
Watch for: a client who cannot voice the deceased (offer to wait, or ask "what do you think he'd say?"); critical replies from "the deceased" (explore them in reflection as the client's own self-judgment) [synthesis]. Signs it is working: relief, a sense of being heard or forgiven, warmer connection. Pilot case material reports a relieving re-enacted goodbye and apology at the casket, and a distressing sickroom image that changed with repetition. These were individual variants, not standard steps. [source: Harkness et al. 2002]

4.16 Midcourse review (session 10)

Purpose: a joint, measurement-based stocktake to plan the last six sessions. [source: Day 2 slides]
Steps: (1) Re-administer the ICG, TBQ and GRAQ and compare with baseline. The slides' example shows the ICG falling from 67 to 38. (2) Ask open questions: how things are going from the client's view; questions about treatment; original expectations and whether they are being met; then and now; what remains; whether other losses need work; goals for the remaining six sessions. (3) Go through each procedure: diary, goals, rewarding activities, imaginal and situational revisiting, the visitor relationship. (4) Summarise progress and agree a plan. [source: Day 2 slides]
Example language (illustrative): "We're at the halfway point. Your grief score has come down quite a bit. Does that match how it feels? What would you most want to have changed by session 16?"
Watch for: little change in scores or in avoidance. Use this to adjust (more situational revisiting, a session on a specific derailer) rather than repeating more of the same. [source: Day 2 slides] [synthesis: the adjustment logic]

4.17 Planning for difficult times (closing sequence, and ahead of any anniversary during treatment)

Purpose: prepare for predictable surges of grief at holidays (especially winter holidays), birthdays, wedding anniversaries, the anniversary of the death and life milestones such as graduations, instead of "hiding and hoping for the best". [source: Day 2 slides]
Steps: identify the next difficult date. Plan the day using four elements: (1) a plan for how the day will go; (2) self-care and positive emotion; (3) help and support from others; (4) a way of honouring the deceased. Write it down. The manual includes a Difficult Times form and a family handout on managing difficult times. [source: Day 2 slides; Manual preview]
Example language (illustrative): "His birthday is in March. What would make it a day that honours him and also looks after you? Who would you want around?"
Watch for: plans that consist only of avoidance. It is working when the client meets the date with a plan and reports it was hard but manageable.

4.18 Termination sequence (sessions 13–16; ending first raised in session 11)

Purpose: use IPT's role-transition approach to ending, so the client leaves with gains consolidated and plans in place. [source: Day 2 slides]
Steps: put termination on the agenda four sessions before the end and give it more time each session. Four before the end: note that three remain and ask about thoughts and feelings. Three before: ask again; discuss future plans and difficult times. Two before: review feelings and plans; identify the next difficult time. Final session: review the therapy and the healing milestones, the gains, and the client's practice of new thinking and behaviour. Then cover what is unfinished (remaining goals work, how comfortable the client is working alone), the plan for the next difficult day, strengths and vulnerabilities, and feelings about ending. You may share your own experience of ending if the client agrees. Agree on future contact (scheduled or as needed) and say goodbye. Throughout, acknowledge what helped and what was hard, anticipate problems, and name the opportunities of ending (free time, testing skills, confidence). [source: Day 2 slides; Manual preview (session 16)]
Example language (illustrative): "We have three sessions left. What comes up for you when you hear that? … Endings can stir up the bigger ending you've been grieving, so let's talk about it openly."
Watch for: ending reactivating the loss. If the client may not be ready (insufficient progress, risk of backsliding, cannot manage without weekly contact, other problems), discuss it. If you disagree, support ending. If you agree, plan next steps together. [source: Day 2 slides]

5. Handling problems

The Day 2 slides present several training vignettes without model answers. The responses given for those are my own synthesis and are marked so.

5.1 Reluctance to do the activating procedures

Shear: clients commonly push back. Explain the rationale for revisiting early and introduce painful tasks gradually rather than all at once. [source: Carlat 2023]
Link the procedures to the client's own derailers and goals. Stress that the procedures are time-limited and contained and end with setting the story aside. Offer choices within the procedure (where to start the list, who comes along). [synthesis]
If the client still refuses imaginal revisiting, keep going with the other milestones and come back to it. Imaginal revisiting is the core of milestone 5, so name the trade-off honestly. [synthesis]

5.2 Diary non-adherence

The slides' vignettes: a client records only the extremes with no notes and asks whether she must keep going; another fills it in from memory just before the session and feels she "should be doing better". [source: Day 1 slides] Responses [synthesis]:

Re-elicit the purpose (getting to know her grief, not proving progress). Ask what she has learned from it so far, then shrink the task to one high and one low with one line each.
Treat "should be doing better" as a derailer (self-judgment). Validate it, and repeat that there are no target numbers.
Problem-solve when and where she fills it in, for example tied to an existing evening routine. Review whatever she did bring rather than the gaps.

5.3 "I have no one to invite" (the slides' "don't want to burden them" vignette)

[synthesis] Explore the belief that she would be a burden as a relationship derailer. Ask whom she would invite if burden were not an issue, and how she would feel if that person asked her. Widen the field (a friend, neighbour, faith community member, adult child by video). If no one is possible yet, use session 3 to map her network and plan one small contact, then hold the visitor session later. Keep watching for isolation.

5.4 A family member thinks the treatment is cruel (the slides' "this will make her feel worse" vignette)

[synthesis] Validate the protective intent. Explain that avoidance keeps grief raw, that revisiting is brief, structured and always followed by setting the story aside and something rewarding, and that distress usually falls over repeated tellings. Ask the visitor to support her doing the plan rather than shielding her. The pilot authors emphasised explaining exposure fully to families and giving maximal support. [source: Harkness et al. 2002]

5.5 Distress stays high, or the client stops listening to the recording

The slides' checklist: look for other derailers and consider giving a whole session to one; explore unspoken derailers such as low self-compassion, worry about getting better, and survivor guilt; check whether the client can set the story aside and does rewarding activities; assess social support and other problem behaviours; slow the pace, frequency or intensity of telling and listening. [source: Day 2 slides] Practical ways to slow it [synthesis]: shorter tellings, listening every other day, listening with a support person present, more grounding at step 3, and moving the listening to the morning if it is being done at night.

5.6 All-or-nothing situational revisiting (the slides' "Margie" vignette)

After manageable brief practice with a baby blanket, she opened a whole box of baby clothes, peaked near the top of the scale and stopped practising. [source: Day 2 slides] Response [synthesis]: praise the courage, then review the before/peak/after ratings. Normalise that a big jump overshoots. Re-establish the "challenging but doable" rule and break the box into steps (one item, then several, with a companion). Plan to practise the next step soon, so that stopping does not become new avoidance.

5.7 "Everything is 100" (the slides' "Ben" vignette: ashes and belongings all rated above 100)

[synthesis] Accept the ratings without arguing. Widen the list to include smaller, more peripheral reminders (a photo in another room, a song, a shop he used). Or use the less formal alternative: plan a meaningful activity that honours the son rather than an exposure item. Start with something motivated or necessary, and let the first success re-anchor the scale. [partly sourced: Day 2 slides list the motivated/necessary starting rule and the informal alternative]

5.8 Cannot imagine any goal, or responds with irritation

The vignettes: a client fixed on the injustice of the death, and one who offers what others expect of her. [source: Day 1 slides] Use the slides' options for stuck clients (childhood dreams, others' pursuits, brainstorming, values card sort, goals questionnaire, occupational counselling), and remember that talking about values alone can raise hope. [source: Day 1 slides] [synthesis] Reflect the protest itself ("it feels wrong to want anything when this was so unfair"). Separate "should" goals from wants. Accept a very small goal.

5.9 Overwhelm or dissociation during revisiting

[synthesis] Signs include a flat or absent voice, lost time, the client not answering rating requests, or a dramatic rise without leveling. Have the client open their eyes, orient to the room (feet on the floor, name objects, describe the day), and slow their breathing. Then reflect briefly and set the story aside as usual. Next time, shorten the telling, keep eyes open, or tell it in the past tense. Consider whether PTSD from the circumstances of the death needs targeting.

5.10 Suicidal ideation

In PGD, suicidal thoughts are often about joining the deceased or not wanting to live without them, and may come with a sense of not being fully present. Ask directly, especially when identity disruption is present. Imminent risk is to be addressed before PGDT. [source: Day 1 slides; Carlat 2023]
[synthesis, following standard risk practice] Ask at intake and when grief scores spike (anniversaries, the start of revisiting, termination). Ask about passive wishes to die, intent, plans, preparations, past attempts, alcohol, access to means, and the anniversary of the death. Make a written safety plan (warning signs, coping steps, contacts, crisis lines). Do lethal-means counselling: secure storage or temporary removal of firearms and stockpiled medication, including the deceased's leftover medicines. Involve the visitor or family with consent. Bereaved by suicide clients carry elevated risk, so assess routinely. Raise the level of care when risk is imminent. Revisiting can continue alongside monitoring when risk is low and a safety plan is in place.

5.11 Traumatic death and co-occurring PTSD

Shear: PGD often co-occurs with PTSD and depression, which can be treated alongside it. Treatment works less well if the grief is missed. Decide which is primary at intake. [source: Carlat 2023; Day 1 slides]
[synthesis] For violent deaths, or deaths the client witnessed, the story may be dominated by fear and threat images. If fear-based intrusions predominate, consider trauma-focused treatment first, or keep the imaginal revisiting focused on learning of the death and avoid lingering on gratuitous injury detail. Watch the reflection step for threat-related as well as loss-related derailers.

5.12 Depression and medication

Shear reports that in the trial of the original treatment, only the therapy arms separated from placebo; citalopram did not, although about two-thirds of participants were also depressed. [source: Carlat 2023] Coordinate with the prescriber on any medication; this guide gives no dosing. [synthesis]

5.13 Escape behaviours (alcohol, staying in the deceased's room, isolation)

The slides list these as problem behaviours and derailers. [source: Day 1 slides] [synthesis] Name the function (escape from pain). Add them to the formulation. Replace them with planned rewarding activities and situational revisiting. Treat substance use disorder first if it would make revisiting unsafe.

5.14 Fear that getting better betrays the person, or survivor guilt

Hidden derailers per the slides. [source: Day 2 slides] [synthesis] Return to the premise that grief is love finding a place, not ending. Use memories work and the imaginal conversation to show that the bond continues. Ask what the deceased would want for them.

5.15 Alliance ruptures

[synthesis] Typical triggers are feeling pushed into revisiting, feeling the therapist does not understand the relationship, and the therapist offering comfort or fixes that feel dismissive. Notice disengagement (missed homework, shorter answers). Name it and ask about it without defensiveness, take your share of responsibility, and renegotiate the pace while keeping the structure. Return to pure active listening for part of a session if needed. The slides' insistence on non-judgment and on not offering unsolicited advice is the main prevention. [source for prevention: Day 1 and Day 2 slides]

5.16 The therapist's own reactions

Expect the work to stir your own fears about death and loss. Work them through rather than avoiding the painful procedures. [source: Carlat 2023; Day 1 slides] [synthesis] Use supervision or consultation. Columbia offers training and group consultation. Watch for your own urge to rescue during the telling.

5.17 Other situations the sources do not address [synthesis throughout]

Multiple or later losses: finish the target loss first. The midcourse review can consider work on other losses.
Unclear facts, inquests or lawsuits (suicide, homicide, medical error): keep revisiting to what the client experienced and knew. Separate legitimate action (legal, complaints) from rumination. Plan for court dates and media coverage as difficult times.
Cultural and religious practice: PGD requires grief to exceed cultural norms, so check with the client and community what is expected. Adapt imaginal conversation wording to beliefs about the dead, for example as prayer or a letter, while keeping its function.
Telehealth: agree on privacy for the recording (secure storage, who might overhear). Have the client in a safe, private space. Get an emergency contact and the client's location before each revisiting session.
Not ready to end: follow the slides' rule: discuss; if you disagree, support ending; if you agree, plan next steps together. [source: Day 2 slides]

Sources

Sources:

Books and manuals cited:

Shear MK (2015). Complicated Grief Treatment: Instruction Manual Used in NIMH Grants. Columbia Center for Complicated Grief. Only the preview was seen.
Shear MK, Frank E, Feske U (1998–1999). Traumatic grief treatment manual, unpublished. Known only via Harkness et al. 2002.

Further reading (not drawn on): the Iglewicz et al. 2020 Depression and Anxiety CGT protocol paper (Wiley), Shear 2012 Dialogues in Clinical Neuroscience, Semantic Scholar, and the CGT Manual Preface PDF. Details these may contain, such as session length, form 5 and suicidality guidance in the manual preface, are marked [uncertain] above.

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