The Grief Gap: The Rise of Structured Grief Therapy in Clinical Practice
Despite rising demand post-COVID, most CBT therapists remain uncertain about structured grief interventions. An NHS pilot offers hope—and highlights the training and research gap.
Despite the growing demand for bereavement mental health support, many CBT therapists report uncertainty about how to address prolonged grief in a structured evidence-based way.
While CBT offers frameworks for treating depression and anxiety, grief related distress; when it becomes prolonged and functionally impairing, often falls outside of standard conventional protocols.
Therapists may ask: How do I differentiate between normal grief and a disorder that requires targeted intervention? Or Is CBT even effective for something as deeply personal as grief?
In the wake of the COVID-19 pandemic, suicide rates, unexpected deaths, and social isolation contributed to a significant rise in complex bereavement presentations in clinical settings1. Yet many therapists still lack specific training to support individuals with prolonged grief disorder (PGD), leading to treatment mismatches, diagnostic errors, or patients disengaging from therapy.
We examine a recent NHS CBT pilot of treatment for Prolonged Grief Disorder Therapy (PGFT) and consider the clinical implications for CBT therapists: Can PGDT be effectively delivered in the NHS setting? And how might it enhance outcomes for clients experiencing PGD?
What is PGD?
PGD is a recently formalised diagnosis which has now been recognised in both the ICD-11 and DSM-5. It describes a persistent and debilitating grief response lasting at least six months after a bereavement, characterised by symptoms like an intense yearning for the deceased, emotional numbness and difficulty re-engaging with life2.
PGD follows a distinct course and does not typically respond to generalised treatments for mood or anxiety disorders. This distinction is imperative for CBT clinicians where structured protocol based treatments are the norm.
Historically, grief was considered a non-pathological human experience unless it triggered another diagnosable disorder. However, over the past two decades research has supported the idea that some individuals experience a form of grief so prolonged and impairing that it becomes a disorder.
In response, Dr Katherine Shear and colleagues developed PGDT, an intervention combining CBT, exposure-based techniques, and attachment informed strategies3.
PGDT has demonstrated significant clinical effectiveness, yet its integration into routine care remains limited.
Current State of Prolonged Grief Interventions
The 2024 pilot study4 reported significant clinical improvements among participants and highlighted PGDT’s compatibility with core CBT principles, such as structured goal setting, cognitive restructuring, and behavioural activation.
Practically, therapists followed a 10–12 session model that included psycho-education, loss-processing tasks (for example, guided imagery), behavioural experiments, and future goal setting5.
Therapy included:
Understanding grief
Managing grief-related emotions
Imagining a promising future post loss
Strengthening relationships
Telling the story of the death
Living with reminders of loss
Connecting with memories of the deceased.
Techniques used include monitoring, psycho-education, goal setting, imaginal/guided revisiting, situational revisiting, and an imaginal conversation.
PGDT’s structure allowed therapists to hold space for both emotional processing and practical change, helping clients move from “grief stuckness” to re-engagement with life.
Importantly, therapists involved in the pilot reported increased confidence in working with grief, with several noting the value of guided imaginal techniques to access avoided thoughts and feelings.
Nonetheless, widespread implementation requires systemic changes. Services would need to invest in training and supervision, adjust clinical outcome measures to capture grief specific changes, and ensure cultural sensitivity in the application of PGDT.
This pilot serves as one of the first examples of PGDT being embedded within NHS Talking Therapies, suggesting that therapists can be trained to deliver grief specific interventions effectively with appropriate supervision and guidance. Yet, outside of this pilot, most services and therapists still lack a clear standardised approach.
Despite the increased prevalence of prolonged grief following COVID-19, especially among those experiencing multiple or traumatic losses there remains no nationally commissioned grief pathway across NHS Talking Therapies in England, leaving local services to decide how, or whether, to respond.
Key Considerations and Challenges for Therapists
The integration of PGDT into CBT raises many clinical, ethical, and operational considerations.
On one hand, structured interventions offer clarity and containment for both therapist and client. PGDT’s focus on grief specific processes such as revisiting the loss narrative, addressing avoidance, and restoring life goals resonates with CBT’s directive approach.
However, some clinicians express concern that grief, particularly when rooted in cultural or spiritual traditions, may resist understandably being “treated” in a clinical sense. As one NHS clinician noted during the 2024 pilot, “The challenge is balancing a protocol with the deeply human side of grief. You need to know when to push and when to sit in silence”6.
Another key limitation is the emotional demand PGDT places on therapists. Revisiting loss narratives and facilitating imaginal conversations with the deceased, as PGDT encourages, can be intense for clinicians not used to working with bereavement in such depth. Vigorous supervision structures and sufficient training time are therefore imperative.
In addition, grief presentations are often complicated by co-morbidities such as trauma or substance use, which may require integrated or staged interventions. Without clear diagnostic boundaries, there is a risk of either over pathologising normal grief or under-recognising clinical PGD, both of which can impair therapeutic progress7.
Key Takeaways
The integration of PGDT into NHS Talking Therapies marks a significant shift in how we conceptualise and treat complex bereavement. As the 2024 pilot demonstrates, CBT informed grief interventions can be both effective and practical, especially when supported by adequate training and clinical oversight.
However, to truly meet the needs of clients experiencing Prolonged Grief Disorder, we need more than pilot studies. Additional research in how grief specific care can be sustainably embedded into mainstream psychological services and therapies is necessary.
This includes updating clinical competencies, developing consistent referral pathways, and ensuring therapists feel emotionally and culturally equipped to navigate the complexities of grief.
Moving forward, questions remain:
Should grief be treated as a discrete clinical issue, or should we take a broader approach that blends therapeutic models with compassion-focused, culturally informed support?
As CBT therapists, we must ask ourselves what it means to “treat” grief especially in a society still grappling with mass bereavement and loss.
Are we able to maintain the structure of evidence-based practice while honouring the deeply personal and, at times, profound dimensions of loss?
Continued dialogue, innovation, and interdisciplinary learning will be vital in shaping the future of grief care within psychological services. This interview with Katherine Shear also provides further helpful information.
What do you think? Is grief better supported outside of protocol driven models? Or have you found CBT or other therapies helpful for your clients?
Author: Jessica Rodrigues