A Cognitive-Behavioral Conceptualization of Complicated Grief.
Abstract
A cognitive-behavioral conceptualization of complicated grief (CG) is introduced that offers a framework for the generation of hypotheses about mechanisms that underlie CG and that can be targeted in treatment. Three processes are seen as crucial in the development and maintenance of CG: (a) insufficient integration of the loss into the autobiographical knowledge base, (b) negative global beliefs and misinterpretations of grief reactions, and (c) anxious and depressive avoidance strategies. These processes are offered to account for the occurrence of CG symptoms, whereas the interaction among these processes is postulated to be critical to symptoms becoming marked and persistent. The model recognizes that background variables influence CG, but postulates that this influence is mediated by the model's three core processes.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Unnatural losses may cause more mental health difficulties because of the disruption of positive and self-evident assumptions about the world and due to more intrusive and negative memories.
“Theoretically, unnatural losses may cause more mental health difficulties because of the disruption of positive and self-evident assumptions about the world (i.e., 'the world is a safe place') and due to more intrusive and negative memories.”
From The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis (2020) · cites this paper as Boelen et al., 2006
Bereavement due to unnatural loss leads to more disturbances indicative of a diagnosis of PGD than bereavement due to non-violent loss.
“Therefore, our results support the assumption that bereavement due to unnatural loss leads to more disturbances that are indicative of a diagnosis of PGD than bereavement due to non-violent loss (Boelen et al., 2006;Djelantik et al., 2017b;Farberow et al., 1992;Figley et al., 1997;Kaltman and Bonanno, 2003;Murphy et al., 1999).”
From The prevalence of prolonged grief disorder in bereaved individuals following unnatural losses: Systematic review and meta regression analysis (2020) · cites this paper as Boelen et al., 2006
Proposed core maintaining mechanisms in prolonged grief disorder are inability to integrate the reality of the loss, avoidance behavior, and negative loss-related cognitions.
“Proposed core maintaining mechanisms in prolonged grief disorder are i) the inability to integrate the reality of the loss in autobiographical memory (i.e., lack of acceptance of the loss), ii) avoidance behavior (e.g., social with drawal, avoidance of situations that trigger feelings about the loss), and iii) negative loss-related cognitions (e.g., catastrophic mis interpretations) (e.g”
From Group-based compassion-focused therapy for prolonged grief symptoms in adults – Results from a randomized controlled trial (2022) · cites this paper as Boelen et al., 2006
Cites
Bonanno, G. A. (2004) · American Psychologist · doi:10.1037/0003-066x.59.1.20 · Cited by 6,851 · see citing works
A cognitive model of posttraumatic stress disorder
Ehlers, A., & Clark, D. M. (2000) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(99)00123-0 · Cited by 6,147 · see citing works
Cognitive Therapy of Depression
HOLLON, S. D., & BECK, A. T. (1979) · Cognitive-Behavioral Interventions · doi:10.1016/b978-0-12-404480-7.50012-5 · Cited by 4,685 · see citing works
The construction of autobiographical memories in the self-memory system
Conway, M. A., & Pleydell-Pearce, C. W. (2000) · Psychological Review · doi:10.1037/0033-295x.107.2.261 · Cited by 4,089 · see citing works
THE DUAL PROCESS MODEL OF COPING WITH BEREAVEMENT: RATIONALE AND DESCRIPTION
Schut, M. S. (1999) · Death Studies · doi:10.1080/074811899201046 · Cited by 2,560 · see citing works
Kraemer, H. C., Stice, E., Kazdin, A., Offord, D., & Kupfer, D. (2001) · American Journal of Psychiatry · doi:10.1176/appi.ajp.158.6.848 · Cited by 1,712 · see citing works
A dual representation theory of posttraumatic stress disorder.
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996) · Psychological Review · doi:10.1037/0033-295x.103.4.670 · Cited by 1,696 · see citing works
Temperament, personality, and the mood and anxiety disorders.
Clark, L. A., Watson, D., & Mineka, S. (1994) · Journal of Abnormal Psychology · doi:10.1037/0021-843x.103.1.103 · Cited by 1,685 · see citing works
Psychological theories of posttraumatic stress disorder
Brewin, C. R., & Holmes, E. A. (2003) · Clinical Psychology Review · doi:10.1016/s0272-7358(03)00033-3 · Cited by 1,132 · see citing works
Treatment of Complicated Grief: A Randomized Controlled Trial
Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005) · JAMA · doi:10.1001/jama.293.21.2601 · Cited by 1,097 · see citing works
Ehlers, C. L. (1988) · Archives of General Psychiatry · doi:10.1001/archpsyc.1988.01800340076012 · Cited by 707 · see citing works
Dalgleish, T. (2004) · Psychological Bulletin · doi:10.1037/0033-2909.130.2.228 · Cited by 498 · see citing works
Maintenance of intrusive memories in posttraumatic stress disorder: A cognitive approach
Ehlers, A., & Steil, R. (1995) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s135246580001585x · Cited by 478 · see citing works
NEIMEYER, R. A., PRIGERSON, H. G., & DAVIES, B. (2002) · American Behavioral Scientist · doi:10.1177/000276402236676 · Cited by 373 · see citing works
The efficacy of bereavement interventions: Determining who benefits.
Schut, H., Stroebe, M. S., van den Bout, J., & Terheggen, M. (2001) · Handbook of bereavement research: Consequences, coping, and care. · doi:10.1037/10436-029 · Cited by 241 · see citing works
Self-citationCaring for Bereaved Patients: "All the Doctors Just Suddenly Go"
Prigerson, H. G., & Jacobs, S. C. (2001) · JAMA · doi:10.1001/jama.286.11.1369 · Cited by 200 · see citing works
Effectiveness of grief therapy: A meta-analysis.
Allumbaugh, D. L., & Hoyt, W. T. (1999) · Journal of Counseling Psychology · doi:10.1037/0022-0167.46.3.370 · Cited by 185 · see citing works
Measuring core bereavement phenomena.
BURNETT, P., MIDDLETON, W., RAPHAEL, B., & MARTINEK, N. (1997) · Psychological Medicine · doi:10.1017/s0033291796004151 · Cited by 181 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Boelen, P. A., de Keijser, J., van den Hout, M. A., & van den Bout, J. (2007) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.75.2.277 · Cited by 454 · see citing works
Self-citationDjelantik, A. A. A. M. J., Smid, G. E., Mroz, A., Kleber, R. J., & Boelen, P. A. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.01.034 · Cited by 395 · see citing works
Self-citationPredictors of grief following the death of one's child: the contribution of finding meaning
Keesee, N. J., Currier, J. M., & Neimeyer, R. A. (2008) · Journal of Clinical Psychology · doi:10.1002/jclp.20502 · Cited by 358 · see citing works
Boelen, P. A., & Prigerson, H. G. (2007) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-007-0744-0 · Cited by 288 · see citing works
Self-citationNetwork analysis of persistent complex bereavement disorder in conjugally bereaved adults.
Robinaugh, D. J., LeBlanc, N. J., Vuletich, H. A., & McNally, R. J. (2014) · Journal of Abnormal Psychology · doi:10.1037/abn0000002 · Cited by 219 · see citing works
A Cognitive Attachment Model of prolonged grief: Integrating attachments, memory, and identity
Maccallum, F., & Bryant, R. A. (2013) · Clinical Psychology Review · doi:10.1016/j.cpr.2013.05.001 · Cited by 214 · see citing works
Eisma, M. C., Boelen, P. A., van den Bout, J., Stroebe, W., Schut, H. A. W., Lancee, J., & Stroebe, M. S. (2015) · Behavior Therapy · doi:10.1016/j.beth.2015.05.007 · Cited by 185 · see citing works
Self-citationEisma, M. C., Stroebe, M. S., Schut, H. A. W., Stroebe, W., Boelen, P. A., & van den Bout, J. (2013) · Journal of Abnormal Psychology · doi:10.1037/a0034051 · Cited by 154 · see citing works
Self-citationEmotion Regulatory Strategies in Complicated Grief: A Systematic Review
Eisma, M. C., & Stroebe, M. S. (2021) · Behavior Therapy · doi:10.1016/j.beth.2020.04.004 · Cited by 152 · see citing works
Litz, B. T., Schorr, Y., Delaney, E., Au, T., Papa, A., Fox, A. B., Morris, S., Nickerson, A., Block, S., & Prigerson, H. G. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.07.005 · Cited by 139 · see citing works
The efficacy of a brief internet-based self-help intervention for the bereaved
van der Houwen, K., Schut, H., van den Bout, J., Stroebe, M., & Stroebe, W. (2010) · Behaviour Research and Therapy · doi:10.1016/j.brat.2009.12.009 · Cited by 106 · see citing works
Djelantik, A. A. A. M. J., Robinaugh, D. J., Kleber, R. J., Smid, G. E., & Boelen, P. A. (2020) · Depression and Anxiety · doi:10.1002/da.22880 · Cited by 110 · see citing works
Self-citationGrief interventions for people bereaved by suicide: a systematic review
Linde, K., Treml, J., Steinig, J., Nagl, M., & Kersting, A. (2017) · PLoS ONE · doi:10.1371/journal.pone.0179496 · Cited by 107 · see citing works
de Groot, M., de Keijser, J., Neeleman, J., Kerkhof, A., Nolen, W., & Burger, H. (2007) · BMJ · doi:10.1136/bmj.39161.457431.55 · Cited by 91 · see citing works
Is prolonged grief distinct from bereavement-related posttraumatic stress?
Golden, A.-M. J., & Dalgleish, T. (2010) · Psychiatry Research · doi:10.1016/j.psychres.2009.08.021 · Cited by 84 · see citing works
de Groot, M., & Kollen, B. J. (2013) · BMJ · doi:10.1136/bmj.f5519 · Cited by 83 · see citing works
CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial
Boelen, P. A., Lenferink, L. I. M., & Spuij, M. (2021) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2020.20050548 · Cited by 84 · see citing works
Self-citationBoelen, P. A., Reijntjes, A., & Smid, G. E. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2016.03.004 · Cited by 76 · see citing works
Self-citationThe centrality of a loss and its role in emotional problems among bereaved people
Boelen, P. A. (2009) · Behaviour Research and Therapy · doi:10.1016/j.brat.2009.03.009 · Cited by 75 · see citing works
Self-citationRumination following bereavement: an overview
Eisma, M. C., & Stroebe, M. S. (2017) · Bereavement Care · doi:10.1080/02682621.2017.1349291 · Cited by 73 · see citing works
“This may have negative consequences because such avoidance could interfere with acceptance of the loss and/or could impede integration of one’s personal memories about the loss with existing memories, thereby fueling grief complications (Stroebe et al, 2007; cf. Boelen et al, 2006).”
BackgroundSmith, K. V., & Ehlers, A. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000438 · Cited by 73 · see citing works
Rumination and implicit avoidance following bereavement: An approach avoidance task investigation
Eisma, M. C., Rinck, M., Stroebe, M. S., Schut, H. A. W., Boelen, P. A., Stroebe, W., & van den Bout, J. (2015) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2014.11.010 · Cited by 68 · see citing works
Self-citationBoelen, P. A., & Klugkist, I. (2011) · Anxiety, Stress, & Coping · doi:10.1080/10615806.2010.527335 · Cited by 58 · see citing works
Self-citationProlonged grief symptomatology following violent loss: The mediating role of meaning
Milman, E., Neimeyer, R. A., Fitzpatrick, M., MacKinnon, C. J., Muis, K. R., & Cohen, S. R. (2017) · European Journal of Psychotraumatology · doi:10.1080/20008198.2018.1503522 · Cited by 56 · see citing works
Attentional bias in complicated grief
Maccallum, F., & Bryant, R. A. (2010) · Journal of Affective Disorders · doi:10.1016/j.jad.2010.01.070 · Cited by 57 · see citing works
Boelen, P. A., de Keijser, J., van den Hout, M. A., & van den Bout, J. (2011) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.720 · Cited by 55 · see citing works
Self-citationWittouck, C., Van Autreve, S., Portzky, G., & van Heeringen, K. (2014) · Crisis · doi:10.1027/0227-5910/a000252 · Cited by 49 · see citing works
Davis, E. L., Deane, F. P., Lyons, G. C., Barclay, G. D., Bourne, J., & Connolly, V. (2020) · Journal of Health Psychology · doi:10.1177/1359105317715091 · Cited by 45 · see citing works
Potential use of ayahuasca in grief therapy
González, D., Carvalho, M., Cantillo, J., Aixalá, M., & Farré, M. (2019) · OMEGA - Journal of Death and Dying · doi:10.1177/0030222817710879 · Cited by 44 · see citing works
Attachment and severity of grief: The mediating role of negative appraisal and inflexible coping
Delespaux, E., Ryckebosch-Dayez, A.-S., Heeren, A., & Zech, E. (2013) · OMEGA - Journal of Death and Dying · doi:10.2190/om.67.3.b · Cited by 40 · see citing works
Distinct neural mechanisms of emotional processing in prolonged grief disorder
Bryant, R. A., Andrew, E., & Korgaonkar, M. S. (2021) · Psychological Medicine · doi:10.1017/s0033291719003507 · Cited by 39 · see citing works
de Groot, M., Neeleman, J., van der Meer, K., & Burger, H. (2010) · Suicide and Life-Threatening Behavior · doi:10.1521/suli.2010.40.5.425 · Cited by 34 · see citing works
The push and pull of grief: Approach and avoidance in bereavement
Maccallum, F., Sawday, S., Rinck, M., & Bryant, R. A. (2015) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2015.02.010 · Cited by 34 · see citing works
Lechner-Meichsner, F., Mauro, C., Skritskaya, N. A., & Shear, M. K. (2022) · Psychotherapy Research · doi:10.1080/10503307.2021.1909769 · Cited by 27 · see citing works
Doering, B. K., Barke, A., Friehs, T., & Eisma, M. C. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1630-1 · Cited by 27 · see citing works
Psychological Flexibility and Resilience in Parentally Bereaved College Students
Murrell, A. R., Jackson, R., Lester, E. G., & Hulsey, T. (2018) · OMEGA - Journal of Death and Dying · doi:10.1177/0030222817693154 · Cited by 25 · see citing works
Johannsen, M., Schlander, C., Farver-Vestergaard, I., Lundorff, M., Wellnitz, K. B., Komischke-Konnerup, K. B., & O'Connor, M. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114683 · Cited by 23 · see citing works
An investigation of approach behaviour in Prolonged Grief
Maccallum, F., & Bryant, R. A. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.05.002 · Cited by 16 · see citing works
Yu, M., Tang, S., Wang, C., Xiang, Z., Yu, W., Xu, W., Wang, J., & Prigerson, H. G. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.01201 · Cited by 15 · see citing works
Bottomley, J. S., Campbell, K. W., Feigelman, W., Schamber, E. L., & Rheingold, A. A. (2025) · Journal of Affective Disorders · doi:10.1016/j.jad.2025.02.102 · Cited by 7 · see citing works
The therapeutic use of ayahuasca in grief
González, D., Aronovich, A. A., & Carvalho, M. (2021) · Ayahuasca Healing and Science · doi:10.1007/978-3-030-55688-4_12 · Cited by 5 · see citing works
Bereavement and Complicated Grief across the Lifespan
Znoj, H. J. (2015) · International Encyclopedia of the Social & Behavioral Sciences · doi:10.1016/b978-0-08-097086-8.21012-x · Cited by 1 · see citing works
- Authors
- Boelen, P. A., van den Hout, M. A., & van den Bout, J.
- Affiliations
- Utrecht University (NL)
- ORCID
- Boelen, Paul A.
- Venue
- Clinical Psychology: Science and Practice
- Published
- 2006
- Volume
- 13
- Issue
- 2
- Pages
- 109-128
- ISSN
- 0969-5893 (ISSN-L)
- 1468-2850
- OpenAlex
- W2056793574
- Cited by
- 523
- References
- 18
- Citations by year
- 2026: 31 · 2025: 40 · 2024: 77 · 2023: 36 · 2022: 32 · 2021: 39 · 2020: 33 · 2019: 22 · 2018: 20 · 2017: 37 · 2016: 19 · 2015: 16 · 2014: 21 · 2013: 16 · 2012: 8
- FWCI
- 14.76
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Clinical Psychology Science and Practice (publishedVersion)
- Funders
- Dutch National Fund for Mental Health
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- complicated grief, cognitive-behavioral model, autobiographical memory, avoidance strategies, anxiety, depression, bereavement, therapeutic mechanisms
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
