Haverkampf, C. J. (2020). Communication-Focused Therapy® (CFT) and Grief. In Communication-Focused Therapy® (CFT) Vol IV (pp. 200–220)
Communication-Focused Therapy® (CFT) and Grief
Christian Jonathan Haverkampf, M.D.
Communication-Focused Therapy® (CFT) is a psychotherapy developed by the author, which has been described for a large number of mental health conditions. This article gives a brief introduction to the approach in CFT for grief.
Keywords: grief, Communication-Focused Therapy®, CFT, communication, psychotherapy, psychiatry
Table of Contents
In Western societies, most people define grief as the emotion elicited by involuntary loss. Loss gives rise to grief and the varied emotions included in grief. We associate grief with death of a person with whom the individual has intimate ties; however, people may grieve over other kinds of losses and, in some situations and societies, death of a close friend or family member does not always elicit grief.(Gharmaz & Milligan, 2006) Grief is a response to loss, particularly to a death of someone or an animal, to which a bond or affection was formed. This bond can also be to ideas or even a way of seeing the world. It usually has something to do with things that are being communicated, so that meaningful information plays a significant role in the bond but also in the development of grief. We are with grief from the day we are born, although there are diverse forms of grief from a normal healthy emotions that leads to change and healing to what is sometimes called the ‘pathological grief’, which sticks around and leads to various psychological and physical symptoms. Communication is an important tool in processing and getting over grief. For example, communication barriers erected by grieving children delay problem resolution. Use of the expressive arts—music, art, and body movement—in symbolic communication has shown to help them to express overwhelming feelings and cope with trauma and stress. (Segal, 1984)
The most painful aspect of grief is the loss of a bond, whose need is felt deeply. Living organisms form many bonds that are lastly built on information. The bond is mutually relevant through the exchange of meaningful information (Haverkampf, 2018b). The sense of loss is thus connected with expectation of a future stream of meaningful information that may be lost. Important is to remember though that existing meaningful information is not lost. In a more severe form of grief, however, there may be the sense that meaning is really ‘lost’. In some conditions, patients may really experience a ‘loss’ in the early stages, as for example in the case of Alzheimer’s dementia. But since information can be communicated to save it from getting lost, it may be helpful particularly to a patient suffering from this condition to express themselves in whichever way possible. Communication-Focused Therapy® aims at helping patients to develop communication patterns which facilitate a more open, meaningful and effective communication (Haverkampf, 2017b).
Since all relationships with another living organism are unique, grief over the loss of another human being, for example, touches the question of how to deal with the loss of someone unique and the unique interactions with that person. Internal dialogue may then become a replacement for the missing external dialogue. Interestingly, the better one knows another person, the fuller and more detailed should be the internal representation of another person. In other words, the more I know someone, the harder it is to lose that other person, because I am carrying a better internal representation of them inside me. Grief over the loss of another person, is, however, often greater when we know someone. Maybe, the more we see in someone, the more we also realize what we may not yet know. When small infants form attachments, it may also largely be driven by the need to secure sustenance, but it is also forcefully propelled by the need to build enduring reciprocal lines of meaningful communication, which we may also call attachment. If I am losing contact with a person I am attached to, whether by death, unfriending, physical distance or otherwise, I will feel the messing line of meaningful communication. It is important to note in this regard, that meaning underlies our experienced existence, and some perceived loss of meaning can be so devastating that it feels our very existence is under attack. For example, grief for parents who lost a child is lifelong, becoming the connection between parent and child (Arnold & Gemma, 2008), and there is the risk that a devastating tragedy becomes the linchpin for any future existence.
Traumatic grief is a risk factor for mental and physical morbidity. The results of a study by Prigerson and colleagues suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction. (Prigerson et al., 1997)
Grief comprises a stereotyped set of psychological and physiological reactions of biological origin. It has been hypothesized that the adaptive function of grief is to ensure group cohesiveness in species where a social form of existence is necessary for survival. (Averill, 1968) However, as already mentioned this does not take into account the direct benefit from the future communication of meaningful messages with the person for whom one grieves. It is this future of meaningful interactions that seems to be lost, which seems to translate into a loss of meaning. But if one acknowledges a fundamental connectedness with the world and oneself, which cannot be broken, it becomes easier to deal with the need to relinquish an expectation of a future gain of meaningful information. And in this vein, it is important to note that meaningful information is the currency that underlies any human bond, from the most trivial to the most profound and emotionally saturated forms of attachment between individuals. It all rests on the communication of meaningful information that happened in the past, is happening now, and is expected to happen in the future; communication that makes everything more meaningful.
The first important step is not to disconnect from oneself, but to allow the emotions that are associated with the grief to become aware and be felt. External connectedness is important as well. It has been shown that the establishment of supportive connections is associated with lowered current and remembered grief (Forte, Barrett, & Campbell, 1996). As already mentioned, the potential to communicate in meaningful ways plays a large role in ‘informational’, including emotional, self-regulation, which is also the key to understanding grief. Meaningful communication also helps to adjust the representation of the person lost. If a person has passed away, for example, symptoms of grief usually resolve following revision of the internalized representation of the deceased to incorporate the reality of the death (K. Shear & Shair, 2005). If this does not happen, it usually leads to complicated grief.
Important is to realize that the bond and the other person do not have to be replaced but can be expanded upon through meaningful interactions with oneself and the world. While it is no longer possible to create new meaning in the interaction with the lost contact, new insights into existing meaning can be developed, either in the interaction with someone else or through the use of the representation of the ‘lost’ person. While our capabilities for internal dialogue are important in the process of resolving grief, they often have to be complemented by external communication to introduce flexibility, novelty and change into internal communication patterns which may otherwise become too rigid. Communication-Focused Therapy® (CFT) in particular is aimed at changing communication styles, both internally and externally, to lead to change in feelings, thought, actions and behaviours, which also translates into real changes in the world (Haverkampf, 2010b, 2017b).
Meaningful information is information that leads to the generation of new information. (Haverkampf, 2010a, 2017c, 2018b, 2018d) Meaning is thus an attribute rather than a ‘thing’. If something has meaning, what we are really saying is that it provides us with meaningful information. The meaning of something is the new information it evokes in us. Once meaning has been identified, the novelty of the information can only be maintained if it triggers new information within the changing information space of the individual. (Haverkampf, 2018a) For example, if a stuffed animal has meaning to me, even as an adult, it does so because of other information changes inside me that resonate with the information of the stuffed animal. This is the reason, why something can increase in meaning or decrease in meaning. Many stuffed animals are apparently unlovingly discarded, almost from one day to the next, as the child grows older. The stuffed animal has not changed. It could not. But what has happened is that its information no longer is meaningful within the context of the changing information contained in the person. It does not elicit novelty that manifests in a state of feeling, for example. This is crucial to understand in the context of grief because what is really being grieved is the loss in potential future meaning, which only depends on a person’s existing internal information content and the associated expectation about the future. Since communication patterns affect this internal information content, a change in communication patterns can affect the expectation of future meaning from the other person, a lost source of meaningful information. Communication-Focused Therapy® works with these communication patterns (Haverkampf, 2017b).
It has been proposed from a constructivist psychology perspective that the reconstruction of a world of meaning is the central process in grieving. (Neimeyer, 1999) I would modify this in the sense that meaning cannot be lost, but that the loss of an expectation of meaningful communication in the future with the person one grieves for requires a reorientation in the world to new sources of meaningful information, which in turn asks for acceptance that one source of meaningful communication has stopped, and in many cases has done so permanently.
That it is the loss of a communication channel which is central to the emotional aspect of loss can be illustrated through many situations in the real world. For example, the loss of an infant through stillbirth, miscarriage, or neonatal death is recognized as a traumatic life event. Predictors of development of complicated grief after prenatal loss include lack of social support, pre-existing relationship difficulties, or absence of surviving children, as well as ambivalent attitudes or heightened perception of the reality of the pregnancy. Risk of complicated grief was found to be especially high after termination of a pregnancy due to fetal abnormality. An additional aggravating factor is that if the loss takes place at an early stage of pregnancy there will usually be no funeral or other rituals of mourning, and the loss may remain unacknowledged by the family and friends. Generally, the possibility of saying goodbye after the loss of a significant person is assumed to have a positive impact on the bereaved person. These issues may complicate the grieving process and increase a sense of isolation for the parents.
Rituals seem to be able to help with the long-term effect of grief. In a study by de Wijngaards and colleagues, it was found in a study that parents presenting the body of their dead infant for viewing at home and the feeling of having said goodbye to the child were associated with lower levels of grief. Previously it was common practice to remove a baby quickly after stillbirth, but this policy has been updated in recent years, with the general assumption that seeing and even holding the infant helps the mourning process. Often parents are nowadays encouraged to hold and see their stillborn infant’s dead body. (Kersting & Wagner, 2012)
There is, however, controversy over the practice of holding the stillborn infant’s dead body, and the concept has recently been challenged by recent studies. It has been found that women who hold their deceased infant have significantly higher rates of post-traumatic stress disorder (PTSD), anxiety, and depression even 7 years after the event. It has been reported in these publications that women who hold their dead infant have significantly higher rates of depression than those who only looked at them, and the least impact on depression was found in the mothers who did not have any contact with the fetus. (Kersting & Wagner, 2012) One can speculate here again that it is the very intense and sudden confrontation with the very real loss of the expectation of a very meaningful future communication which can lead to a state in which the emotional and cognitive autoregulatory systems are overwhelmed, and maladjustive processes which lead to depression among other things set in.
It has been argued that the purpose of grief is the construction of a durable biography that enables the living to integrate the memory of the dead into their ongoing lives, and that the process by which this is achieved is principally conversation with others who knew the deceased (Walter, 1996). The objective in the grieving process is not to replace a person or to lose them, but to reopen the dialogue within oneself and to acknowledge that this dialogue does not depend on the other person, that one can build new meaning in the world, which is enriched by the memory of the person, but not dependent on them.
Important is to realise that a good part of the memory one attributes to another person is tied to one’s own processes of communicating and storing information, and this cannot be lost. When one gets stuck in grief and replays interactions of the past, to get unstuck is to realise that what another person contributed will always be present in one’s interactions in the future. No amount of replaying interactions from the past will change this either way. It is important to accept that memories have become part of oneself. Information from an interaction or a series of interactions have become part of the information one has about oneself. As the memories of our experiences change the perspectives and believes we have, we want more of these meaningful interactions in the future. Important is to realise that there is an enormous flow of information taking place everywhere in the world continuously, and that individual streams of information are both connected and share the same foundations. Thus, in every interaction there is a reflection of the meaningful information that comes before and after it. In other words, the slightest glance at the eye of the other reflects myriads of other interactions that are also encoded in this moment. On the other hand, every encounter is unique in its composition of information. Important is to grieve the unique but also to see that it is a reflection of the whole.
Realising that what one has experienced is not lost is not make-belief, but an important part of the grieving process, to become aware of what the dialogue with the other person and the person represents internally, and what is behind it, all the thoughts, emotions and cognitive concepts that in reality belong to the one thinking and feeling them. What we think and feel belongs to us. It is not injected into us by another. We make connections important because we can attach meaning to the information coming from another person as it resonates with information we already have in ourselves. An appreciation for the connectedness in the world, and feeling it, is important in overcoming the disconnectedness one often experiences as part of the grieving process.
The perceived loss has something to do with the influence, or even control we think we need to have over another person, but never really do. We do not own another person, nor do we have real control over another person. However, we can control how we communicate and have more influence than we may think of the bonds we form with others.
The very limited direct influence over others can cause a dilemma if one does not appreciate that the benefit one derives from a relationship lies in the magic of the meaningful communication with the other rather than in having ‘a’ bond with someone else. A bond without the meaningful communication that sustains it is pointless. Once we establish a relationship with someone else and have an emotional investment in it, we stand to lose something that is of value to us. The important aspect to realize is that we can never lose the communication that has been. However, one may fear a change in future meaningful interactions and experiences the world that seem to depend on the other person. However, having different interactions and experiences in the future does not mean that they will be less meaningful. Constructive grief pushes one towards greater openness to the world and embracing change through a rediscovery of the possibilities that lie within meaningful interactions with others. Taking stock of one’s own internal and external communication patterns with oneself and others, reassessing and possibly changing them, are the means to get there.
Grief is a natural response to loss. It is the suffering one feels when something or someone the individual loves is taken away. Attachment to a person, which can be external and real or internal possibly tied to a real object and person, is the expectation or hope of a continued dialogue, a meaningful communication that may never end (Haverkampf, 2017a). Loss can thus also lead to loneliness in the face of the missing communication and something that makes a part of the self more meaningful seems to have been taken away. The grieving process will also heal any seemingly empty gaps that have been left in the sense of self. As the self is our perception of the flows of internal communication (Haverkampf, 2010a, 2012), if a regular interaction and the communication that takes place in it are missing, it can feel as if the self is changing. However, what needs to happen is that it can change, and be open to new information flows that do not simply replace the existing ones, but strengthens the sense of an alive, dynamic and constantly changing perception of the self. The sense of self, on the other hand, remains stable and lends stability to the whole structure of the personality.
Complicated grief is intense grief after the death of a loved one that lasts longer than expected according to social norms and causes functional impairment. (M. K. Shear, 2015) Its symptoms are distinct from those of bereavement-related depression and anxiety. (Prigerson et al., 1996) Individuals with complicated grief have greater risk of adverse health outcomes, should be diagnosed and assessed for suicide risk and comorbid conditions such as depression and posttraumatic stress disorder, and should be considered for treatment. (Simon, 2013) A new diagnosis of complicated grief disorder has been suggested indicated. Its criteria would include “the current experience (more than a year after a loss) of intense intrusive thoughts, pangs of severe emotion, distressing yearnings, feeling excessively alone and empty, excessively avoiding tasks reminiscent of the deceased, unusual sleep disturbances, and maladaptive levels of loss of interest in personal activities.” (Horowitz et al., 2003)
There are several therapeutic approaches to complicated grief. In interpersonal psychotherapy (IPT), the therapist helps patients to arrive at a more realistic assessment of the relationship with the deceased, addressing both its positive and negative aspects, and encouraged the pursuit of satisfying relationships and activities. Added may be addressing traumalike symptoms using procedures for retelling the story of the death and exercises entailing confrontation with avoided situations, modified from imaginal and in vivo exposure used for PTSD (“revisiting”) (K. Shear, Frank, Houck, & Reynolds, 2005).
Attachment activates reward pathways. Complicated Grief occurs when an individual experiences prolonged, unabated grief. The neural mechanisms may include both pain-related activity (related to the social pain of loss) and reward-related activity (related to attachment behavior). Data from a study by O’Connor and colleagues revealed that whereas both complicated and non-complicated grief participants showed pain-related neural activity in response to reminders of the deceased, only those with complicated grief showed reward-related activity in the nucleus accumbens, which was also positively correlated with self-reported yearning. This study supports the hypothesis that. For those with complicated grief, reminders of the deceased still activate neural reward activity, which may interfere with adapting to the loss in the present. (O’Connor et al., 2008)
The grief associated with death is familiar to most people, but individuals grieve in connection with a variety of losses throughout their lives, such as unemployment, ill health or the end of a relationship. Loss can be categorized as either physical or abstract, the physical loss being related to something that the individual can touch or measure, such as losing a spouse through death, while other types of loss are abstract, and relate to aspects of a person’s social interactions. However, what all types of loss have in common is that another point of communication, and thus the existing communication with it, has been lost. The more one becomes aware of what has been communicated, its meaning, and how this was communicated, the easier it is to resolve emotionally the loss.
From a CFT perspective, emotions can be adequately resolved when they are communicated in an effective form. Grief tends to perpetuate itself if communication patterns that could otherwise help to move the grieving process forward and resolve the grief are impaired. This can often happen in there are prior negative experiences that led to communication patterns which over time have become maladaptive or ineffective or are used in the wrong situations and for the wrong purposes.
Grief may often also trigger past emotions that may never have been adequately resolved and seem dormant but are reactivated by a though or emotion that trigger images and other complex information, which then trigger thoughts and emotions with a negative valence. Although life moves on more or less along a continuum, a loss can be experienced like a sudden rupture or even chasm on the timeline of life and will do so until the loss is processed. It is one of the purposes of grief to create this rupture in time, which in the best-case scenario can provide the space to process the information that needs to be processed as part of the griever’s journey. This processing happens through communication externally and internally, with others and with oneself. In this process new meaning is created which does not replace the lost meaning, but increases the size of the retained meaning, while reducing the meaning that seems lost. The reason is that if something was shared, the memories and all other information about the relation and its meaningful interactions when communicated and shared rebuilds and conserves meaning.
The use of communication is what brings about change. Meaningful communication can lead to a resolution of the grief and transmorph it into something different. The work with communication patterns has been described by the author in more detail elsewhere. (Haverkampf, 2018c)
Communication follows laws like physical phenomena, but since even during an interpersonal everyday interaction between two people, a large multitude of different strands of communication occur almost simultaneously, one often needs to approach the patterns that emerge depending on the situation heuristically or at best probabilistically. In CFT communication patterns are used by both therapist and patient, but they are also a tool the therapist can use to bring the patient’s communication patterns into their awareness and make them accessible to change. How communication patterns can be used by the therapist to help patients change maladaptive and dysfunctional communication patterns is described in greater depth elsewhere (Haverkampf, 2018c, 2019). Important is that the therapist develops an understanding where the patient is cognitively and emotionally, which is reflected in the communication patterns the patient uses (Haverkampf, 2010a, 2010b). This is insight helps in selecting and using communication patterns that help the patient to make adjustments and experiment with new ways of internal and external communication.
The environment plays a significant role in the development and outcome of grief. People usually do not grief in a vacuum. This is also why communication is important for someone who is grieving. The better and more helpful the communication is, the greater are the chances that the grieving process can be resolved within a sensible time. This communication has internal and external components. Social rituals and other processes come with their own communication patterns, which can be helpful for the individual, but to open up to these different forms of communication requires that the individual can overcome fears that are often associated with opening up to a greater communication about hurtful emotions.
Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at email@example.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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 In this context, the term person does not necessarily only refer to a human being but can also include a non-human companion, as personality is inherent in the patterns of communication a complex organism uses.