Letter Writing as a Clinical Tool in Grief Psychotherapy

Abstract

The benefits of expressive writing have been explored since at least the 1980s. The effect of expressive bereavement-related writing has been studied primarily in college students, yielding inconclusive results. Nonetheless, recent effective, integrated psychotherapy protocols, targeting complicated and prolonged grief, include writing assignments, typically in the form of letters. The present paper explores how and why letter writing might be effective and meaningful as a therapeutic tool in the context of grief psychotherapy. It describes how working with letters, addressed to the deceased, might help facilitate self-disclosure, promote exposure to what is avoided, confront unfinished business, encourage continuing bonds, and help achieve a coherent narrative around experiences with the loss. As a therapeutic tool, letter writing has the potential to be helpful to many bereaved people, as it is a simple, effective, and meaningful way to access and work with relevant clinical material in the context of psychotherapy.

Keywords

bereavement prolonged grief psychotherapy therapeutic tools letter writing

Bereavement following the death of a loved one is a highly stressful life event, one that places the bereaved person at risk of decreased mental and physical health, as well as increased risk of mortality (Guldin et al., 2017; Rostila et al., 2018; Stroebe et al., 2007). While estimates suggest that about 60% of people experience a gradually healing grieving process and recover on their own, approximately 40% of bereaved adults may need some form of psychosocial support (Bonanno et al., 2011; Killikelly et al., 2021). About 10% of adults bereaved due to natural causes (e.g., illness) are likely to experience Prolonged Grief Disorder (PGD), i.e., a high level of persistent and impairing grief (Killikelly & Maercker, 2017; Lundorff et al., 2017; WHO, n.d.), while the same is true for up to 49% of adults bereaved due to non-natural causes (e.g., suicide, homicide, and disasters; Djelantik et al., 2020). This paper is concerned with grief responses, which, like PGD, are severe, prolonged, and disabling, and thus requiring psychotherapy.

Prolonged Grief Disorder (PGD) is included as a new diagnosis in the ICD-11 (WHO, n.d.) which went into effect in January 2022. Much research has gone into defining the diagnostic criteria for PGD (Lenferink et al., 2019). The criteria include persistent yearning/longing for the deceased, preoccupation, emotional distress due to, for example, difficulty accepting the death, disbelief or emotional numbness, bitterness or anger, and identity disruption, which is accompanied by functional impairment (American Psychiatric Association, 2013; Killikelly & Maercker, 2017; Lenferink et al., 2019; Prigerson et al., 2009; Shear et al., 2011; Shear, 2015). See Killikelly and Maercker (2017) for a full description of the diagnosis.

Because of the negative consequences associated with pathological grief responses, several psychological interventions for bereaved adults have been developed. To date, the strongest evidence has been found for individual therapy utilizing a cognitive behavioral approach (Boelen & Smid, 2017; Johannsen et al., 2019; Wagner et al., 2020). A cognitive behavioral conceptualization of pathological grief suggests that a state of acute grief is prolonged (maintained) by an insufficient integration of the loss with preexisting knowledge; rigid negative thinking about oneself, life, and one’s ability to deal with the loss; and a tendency to fear and avoid reminders of the loss and withdraw from normal routines and activities (Boelen et al., 2007). To address this, cognitive behavioral therapy (CBT) approaches for pathological grief typically include psychoeducation, cognitive reappraisal (i.e., addressing dysfunctional thoughts and catastrophic misinterpretation), exposure/confrontation, goal-setting, and integration of the loss into the bereaved person’s life narrative (P. A. Boelen et al., 2007; 2010; Bryant et al., 2017; Lichtenthal et al., 2019; Rosner et al., 2011; M. K. Shear & Gribbin Bloom, 2017; Wagner et al., 2006). Grief CBT procedures typically also incorporate elements from other grief-related theoretical schools of thought. An example being including the importance of re-defining, and thus continuing, the relationship or bond with the deceased, rooted in attachment theory (see Bowlby, 1980). Another example being acknowledging the importance of understanding (i.e. making sense of) and finding meaning in the loss experience, rooted in a meaning constructionist framework (Archer, 2008; Gillies & Neimeyer, 2006; R. A. Neimeyer, 2001). As well as having a focus on restoration or construction of identity, emphasized in both the meaning constructionist framework and the dual process model of coping with bereavement (Stroebe & Schut, 1999). As such, effective interventions tend to be integrative and able to accommodate the complexity and individual nature of severe, pathological grief.

A recent scoping review suggested that effective treatments for pathological or complicated grief also incorporate work with rituals and symbolic expression and interaction (Wojtkowiak et al., 2021). This includes symbolic dialogue with the deceased, writing assignment, and farewell ceremonies. Rituals and symbolic experiences can be useful in working on the relationship and continuing bond with the deceased. It is difficult, however, to pinpoint the specific effect of using rituals and symbolic experiences, as the effectiveness of therapy typically is evaluated by looking at the therapy as a whole and not the individual treatment components.

This article will explore the potential of using letter writing, a symbolic communication with the deceased, as a therapeutic tool in therapy targeting severe, pathological grief responses. Several effective treatment protocols (e.g. Boelen et al., 2007; Eisma et al., 2015; Wagner et al., 2006) incorporate letter writing, but a thorough discussion of the reasons why letter writing is a beneficial tool is not typically discussed in any great detail. This article will begin to address this gap by providing an introduction to expressive and letter writing in the context of grief therapy. Then it will review the role of letter writing in effective grief treatments. This is followed by a description of how letter writing can be used as a clinical tool in therapy. Finally, the multiple ways in which letter writing may be particularly well suited to incorporate in grief therapy are discussed, including the potential reasons why that is.

The discussion of the clinical usefulness of writing letters to the deceased in the context of grief therapy is in part based on the author’s own work with bereaved young adults aged 20–27 years. This work has primarily involved treating parentally bereaved young people in a group therapy setting. The treatment method has been developed over several years, is eclectic in its approach, and letter writing is one of the primarily tools used to facilitate the therapeutic work. The method is described in greater detail elsewhere (Larsen et al., 2021).

Expressive Writing in Context of Bereavement

The therapeutic benefit of expressive writing has been explored for decades, starting with the work of Pennebaker and colleagues (Pennebaker et al., 1988; 1990; Pennebaker & Francis, 1996). In traditional therapeutic expressive writing scenarios, clients are instructed to disclose their deepest thoughts and feelings about the stressful or traumatic events, writing 20 minutes a day for 4 consecutive days (Pennebaker & Slatcher, 2004). Evidence supports the benefits of such emotional experimental disclosure related to distressing events on both physical and mental health (Frattaroli, 2006), in part due to facilitation of insight (Pennebaker, 1997) and emotional acceptance (Baum & Rude, 2013) as well as confrontation with that which is avoided (Frattaroli, 2006; van der Houwen et al., 2010).

In the context of bereavement, the effects of expressive writing assignments in the traditional sense have been studied primarily in college students and have been inconclusive (Lichtenthal & Cruess, 2010; Rubin et al., 2020). Even when directed to write about specific bereavement-related topics, for example writing about the deceased, memories, and the loss, the results have been mixed. Lichtenthal and Cruess (2010) found a positive effect when bereaved participants were directed to focus on sense-making and benefit-finding related to the loss compared to traditional non-directive emotional disclosure. However, Range et al. (2000) found that participants directed to write about their bereavement experience, as well as the control group, which was directed to write about a trivial topic, experienced reduced grief, less anxiety, and depression over the 2-month study period, suggesting time was the effective agent for change. The experimental group rated their writings as more personal, meaningful, and emotional, and indicated that they wanted to talk to other people about their essays, and did talk to other people about their essay topics. This suggests that the grief-focused assignment added motivation to further explore grief-related topics, which could be helpful in a therapeutic context. Rubin et al. (2020) found that positive affect among bereaved people did not improve because of directed bereavement writing (i.e., writing about a positive memory with the deceased) compared to writing about a neutral activity. When looking at mediating factors, they found that participants in the positive memory writing condition with higher grief scores were more likely to show a greater increase in negative affect relative to those with low grief scores. The authors suggested that this could result from being less able to regulate negative emotions (Gupta & Bonanno, 2011). This is another relevant issue to consider when using expressive writing in a therapeutic context. Finally, Thatcher (2020) examined the effect of directed expressive writing in a sample of 12 adults bereaved by addiction within the past 6 years. Eight of 12 participants chose to write directly to the deceased. This was especially the case for those bereaved within the past 2 ½ years. All the participants reported increased self-awareness, as well as sense- and meaning-making, which have been found to be associated with improvement in behavioral regulation as well as physical and mental health (Thatcher, 2020). The author suggested that writing could be a “uniquely valuable therapeutic intervention” in the context of bereavement.

It seems that simply expressing thoughts and feelings in writing, even when directed at bereavement-related topics, has not routinely been found to be effective in reducing grief symptoms in college students. Perhaps the effect is only seen when letter writing in used with a clinical population and as part of a comprehensive treatment approach.

Written Exposure Therapy for PTSD

It is interesting to also briefly look at the use of expressive writing in the context of post-traumatic stress disorder (PTSD) interventions. That is because, following the death of a significant other, symptoms of PTSD and PGD can co-occur, especially in situations where the death was violent or sudden (Eddinger et al., 2021). In fact, a recently meta-analysis estimated the co-occurrence of symptoms of PTSD in patients with PGD to be 49% (Komischke-Konnerup et al., 2021). That is, among bereaved persons with likely PGD, about half also are likely to experience PTSD. Another recent review paper has found that PGD and PTSD can be treated concurrently using both exposure- and non-exposure–based treatments (Eddinger et al., 2021).

There are several evidence-based treatments for PTSD (Watkins et al., 2018), for example, Cognitive Processing Therapy (Resick et al., 2016), Prolonged Exposure (Foa et al., 2007), and trauma-focused CBT (Ehlers et al., 2005; Kubany et al., 2004). However, due to issues with non-responders, dropout rates and lack of access to these treatment methods, alternative treatment options have been explored (Sloan et al., 2012). One such alternative treatment is Written Exposure Therapy (WET) (Sloan & Marx, 2019). WET consists of five weekly treatment sessions, during which patients with PTSD repeatedly write about the traumatic experience, describing the trauma, thoughts and emotions in detail (Sloan et al., 2016). Thus, WET is an exposure-based intervention. A clinician provides instructions for each writing assignment, then leaves during the writing activity, and returns after 30 minutes to instruct the patient to stop writing and to briefly discuss the patient’s reactions to the session (less than 10 minutes). The themes of the writing assignments change from a trauma detail-orientated focus to a more meaning-based one (Sloan et al., 2016). WET has been found to be efficacious, effective and result in lower drop out compare to other effective treatments (Sloan et al., 2012, 2018).

Extending these findings to bereaved individuals, it could be hypothesized that expressive writing might be helpful in alleviating co-occurring PTSD symptoms, and in addressing traumatic experiences associated with the death or the preceding course of treatment, while perhaps not necessarily affecting other symptoms seen in pathological grief, such as prolonged yearning/longing for the deceased, difficulty accepting the death, and identity disruption.

Letter Writing in Effective PGD Treatment Protocols

Even though not consistently shown to reduce grief symptoms in isolation, expressive writing, including letter writing, is incorporated as a clinical tool in several effective treatment protocols for PGD (Wojtkowiak et al., 2021). Wagner and colleagues (2006) reported on an effective Internet-based CBT program for complicated grief with an extensive focus on writing assignments. The treatment was conducted via an e-mail exchange between therapist and client. It focused on exposure to bereavement cues, cognitive reappraisal, and integration and restoration, and involved two weekly 45-minute writing assignments over a 5-week period. The clients were instructed to write essays on the circumstance of the death, particularly difficult and painful memories, compose a supportive and encouraging letter to a hypothetical friend, and to write a letter to a significant person, which could be the deceased, about important memories about the death. These structured writing assignments provided the clients an opportunity to reflect upon and transform their experiences, thus potentially facilitate integration of the traumatic experiences (Wagner et al., 2006).

Rosner and colleagues (2011) described using writing assignments as a possible way to deal with painful moments, and provided a case example where writing letters to the deceased seemed to promote self-awareness, clarity, and motivation for behavioral change.

In Complicated Grief Therapy (Shear, 2017), Shear has described the importance of ‘imaginal revisiting’ and mentioned using an ‘imaginal correspondence’ with the deceased as a clinical tool. Imaginal revisiting is typically done verbally, but there can be occasions where that is too difficult and painful, and where a written format can seem more manageable for the client. In imaginal correspondence, the bereaved person writes letters to and from the deceased person. It is suggested that this technique can be particularly helpful in addressing questions around the circumstances of the death. In a brief example, Shear (2017) described how a man, who had lost his farther, used imaginal letter correspondence with his father to address issues of guilt and worry.

Bryant and colleagues (2014, 2017) included letter writing as a recurrent tool in their CBT protocol for PGD, which has been found to be effective in randomized trials. The treatment consisted of 10 group therapy sessions, followed by 4 individual sessions. Participants wrote letters to the deceased, which served to address unresolved issues, as well as to focus on positive memories and experiences. This in part to help with the cognitive restructuring part of the treatment.

In Grief-Help (Boelen et al., 2019, 2021), a manualized CBT protocol for bereaved children with PGD symptoms, letter writing is used as one of three exposure interventions. The participant is asked to write a letter to the deceased about what is missed most (Boelen et al., 2021).

Boelen and colleagues (2013) have also included letter writing as an imaginal exposure technique in a CBT method developed for adults with PGD. They encourage clients to write a letter to the deceased, focusing on what is missed most due to the death. In addition, the treatment calls for (1) an ongoing farewell letter to the deceased, to share and address unresolved issues and say goodbye; (2) three letters including an angry (negative) letter, a loving (positive) letter, and a balanced (integrated) letter, to address, accept and integrate ambiguous feelings; and (3) a letter to an imaginal friend who is going through the same process, to help someone else as a means to helping oneself (Boelen & O’Connor, 2020). These letters serve as exposure to confront the reality of the loss, as well as exposure to thoughts and feelings associated with the deceased and the relationship. As such, they provide the opportunity to process (integrate) the loss, work on acceptance, clarify what is lost in a balanced way, address the new identity (as one who now can help others in a similar situation), and to maintain contact with the deceased.

Thus, the use of writing assignments, such as letter writing, is seen in several effective treatment protocols, but the rationale behind using letter writing, that is why and how it works well as a tool, is often not thoroughly explained. The remainder of this paper will describe how to work with letters and explore possible reasons for why writing letters to the deceased might be helpful and highly relevant in grief therapy.

How to Work with Letters

The practical aspects of working with letter writing in grief therapy can be relatively straightforward. It is a simple tool that serves to help the client bring forth clinically relevant material (e.g., thoughts, feelings, and memories), reflect on important topics, and organize thoughts and feelings through homework assignments. The letters may also shed light upon how the client processes grief-related material, for example, by endorsing dysfunctional thoughts and/or engaging in catastrophic misinterpretation. Clinical material as well as dysfunctional thought patterns and misinterpretations can then be addressed in the therapy sessions. Studies have found that emotional disclosure through writing homework in conjunction with outpatient psychotherapy facilitates therapeutic process and outcome (Graf et al., 2008).

The letters described in this paper are addressed to the deceased, but sometimes it might be helpful to write to another person, for example, a relative or the client him or herself (perhaps a younger or future self). The letter starts with a greeting, such as “Dear mom” and ends with an ending salutation, such as “I miss you. Love, Anna.” The exact wording is up to the client. The letter does not have to be of a particular length or to be grammatically correct for that matter. It can be handwritten or typed. The client should be instructed to store the letters together, for example, in a journal or electronic folder, where they are easily accessible. If a letter is addressed to a living person, the letter could be sent or read aloud to and discussed with that person, if deemed relevant and meaningful by the client and therapist. The rationale for and description of how to use letters in therapy, as described above, should be explained to the client.

The topics of the letters vary depending on what the client is working on. In my experience, it is helpful when the client and the therapist work together to decide the topic. The client should find the writing assignment meaningful, relevant and manageable, and, as a result, the letter should help bring forth clinical material, which is discussed in the subsequent therapy session. Topics can be wide ranging, including writing about the relationship, what is missed since the death, memories and experiences, issues the client is struggling with and so on. It can be helpful to talk to the client about the experience of writing the letter, in part to gauge the relevance and emotional impact of the assignment. If it turns out a letter assignment did not work, for example, if it was too difficult or not meaningful to write, the reasons for that difficulty or experience can be explored in the therapy and may lead to clinically relevant material as well. For example, a client might not have written the letter due to worrying that it might be too emotionally taxing. Then the subsequent session might focus on the fear of being overwhelmed by unpleasant feelings.

Though sometimes viewed as cognitively and emotionally challenging, writing the letters typically becomes an important and worthwhile activity for the client. One of the meaningful benefits to using letters written to the deceased, is that it allows for the deceased person to play a central role in the therapy, which can bring both focus and comfort to some.

One final note. Letter writing should not be thought of as a freestanding complete treatment for pathological grief. Rather, it can be used within an intergraded approach that also includes elements such as psychoeducation, exposure experiments, affect regulation exercises, cognitive restructuring, future goals, and so on. However, letter writing can be considered a technique to provide structure and facilitate access to relevant clinical material within the therapy. In addition, it is a way to engage the client in meaningful homework assignments in between sessions.

Why Work with Letters in Grief Therapy?

After the discussion of how letter writing can be implemented in a therapeutic context, the remainder of the paper will now address some of the reasons why using letters written to the deceased, may be a particularly helpful tool in grief therapy.

Facilitating Self-disclosure When Self-concealment Seems Safer

Self-disclosure is the process by which people let themselves be known to others by actively sharing personal information, such as thoughts, feelings, actions, or events (Jourard, 1971). Several studies have suggested that self-disclosure contributes to healthy adjustment (Levi-Belz et al., 2014; Levi-Belz & Lev-Ari, 2019; Smith et al., 2011). In the context of bereavement, helpful self-disclosure is not limited to talking about personal experiences, but also involves talking about the deceased and the relationship. Consequently, this can help review and discuss significant life events, producing meaningful memories and narratives; it can confirm and validate the deceased person’s past existence; and it can help reinforce and support the bereaved person’s identity, for example, as a parent or partner, despite the death (Riches & Dawson, 1998).

Self-concealment, on the other hand, is the process by which people actively conceal personal information, which could be perceived as distressing or negative by others (Larson & Chastain, 1990). Self-concealment has been found to be associated with negative physical and psychological outcomes (Larson et al., 2015; Larson & Chastain, 1990), likely due to contributing to behavior and strategies that interfere with the ability to regulate emotional distress and integrate difficult life experiences (Larson et al., 2015).

Following the death of a loved one, some bereaved people are motivated to self-conceal for fear of losing control of their emotions, which they perceive as uncomfortable and embarrassing if it happens in front of others. Some conceal their feelings and avoid the topic of death, because they fear “losing control” or “going crazy” if they were to let themselves feel. Others are motivated to self-conceal because they feel a sense of “social disconnectedness” following the death. That is, they fear others’ reactions (“Others cannot handle it, if I share my feelings about the loss”), experience an altered social self (“I am different now. I don’t fit in the way I used to”), and it feels safer being alone where experiences of grief can be expressed (“Only when I am alone, can I be me”) (Smith et al., 2020b). This sense of social disconnection has been found to be associated with higher psychological distress in the first 6 months of the loss, while improved social connection over time seems to reduce psychological distress (Smith et al., 2020b).

Self-concealment in the context of social disconnectedness is evident in the bereavement literature. For example, bereaved parents have been found to feel compelled not to talk about having lost a child, to avoid negative reactions from non-bereaved others, and to avoid unwanted sympathy and embarrassment (Pollock et al., 2020; Riches & Dawson, 1998). But the bereaved parents face a ‘conversational dilemma.’ By trying to avoid talking about their deceased child, they feel compelled to hide, lie about or deny the child’s existence, which has negative implications for the parents’ well-being and identity as a parent (Pollock et al., 2020; Riches & Dawson, 1998). People bereaved by suicide and drug-related deaths, sometimes try to conceal the cause of the death and their grief, to avoid others’ reactions and stigmatization (Pitman et al., 2016; Titlestad et al., 2020). As a consequence, this self-concealment may reinforce a sense of disenfranchised grief (i.e., loss and grief that is not acknowledged by the bereaved person’s network or by society; Doka, 1989, 2008), limiting access to support and potentially impairing their adjustment to the loss (Dyregrov et al., 2020). Thus, while self-disclosure may be helpful, bereaved persons may be reluctant to share their grief and experiences due to a perceived social disconnectedness and stigmatization, making self-concealment the preferred coping strategy.

Psychotherapy is an exercise in self-disclosure. It can help decrease self-concealment and social disconnectedness through interactions with an empathic therapist and with fellow group therapy participants, who can relate. However, psychotherapy and self-disclosure can be intimidating, overwhelming and anxiety producing. It can be helpful to discuss the benefits of self -disclosure, as well as the negative consequences of self-concealment and social disconnectedness to motivate the client to engage in the therapeutic process. Through implementing letter writing as a tool, client is offered a sense of control over what and how much to disclose at a given time. This, may be reassuring and help motivate reluctant clients to engage. Within the therapy, the therapist can help the client narrow the focus of a letter to what the client can bare disclosing at a given time. For example, a letter could be limited to only describing what the client felt and experienced during the funeral. Or a letter could describe one important memory. The client has control over the process and the speed with which to disclose difficult information. Of course, the therapist helps set the goals for the letters, but the client can work on processing thoughts and feelings at home in private at first, before disclosing those to others. Writing and verbalizing difficult thoughts and feelings can help the bereaved look at these in a new light. This, bit-by-bit, perhaps more organized and processed self-disclosure may seem more manageable to a person who has been used to self-conceal. In the therapeutic context, whether it be individual or group therapy, the client’s disclosure will be met with understanding and support. Consequently, the client learns that he/she can indeed handle sharing personal information related to the loss, and that this can be received well by others. Thus, this approach can provide a gentle exposure to difficult material and help address the feelings of isolation and detachment often felt by bereaved people.

Exposure to What is Avoided

Avoidance can play an important role in both adaptive and maladaptive grief. When Stroebe and Shut in 1999 introduced their influential Dual Process Model of Coping with Bereavement (DPM), they described how bereaved people tend to oscillate between loss-oriented and restorative processes, as they cope with a loss (Stroebe & Schut, 1999). The oscillation between the two processes allows the bereaved person to engage in one process, while taking a break from (avoid) the other. Adaptation seems to be facilitated by being able to disengage from one process, perhaps when it becomes too difficult or painful, and switch focus to the other. Sometime the bereaved person engages with neither process, finding a way to take a break from grieving all together. Thus, avoidance can be adaptive and help facilitate a healing grief response.

On the other hand, excessive avoidance can lead to maladaptive coping in response to a loss. For example, some bereaved persons seem to engage solely in one of the DPM processes, while completely avoiding the other. An example could be, as in PGD, where a bereaved person is overwhelmed with grief, longing, sadness and a disbelief. It may seem impossible in this state to continue living and seeing a meaningful future. This person is exclusively engaged in the loss-oriented process and is unable to engage in restorative work. On the other hand, some bereaved persons focus almost exclusively on getting on with life, restoring normalcy in day-to-day life, and establishing new relationships. Here, the person might attempt to avoid thinking about the deceased, feeling sad, remembering, and reconnecting with people and places that remind the bereaved of the loss. The motivation may be to avoid negative feelings, fearing that they will be too painful and difficult to handle. In both these cases, this pervasive avoidance is maladaptive in the long run. Thus, it is important to find the right “dose” of avoidance, where it is helpful and assists in the healing process, as opposed to hinder it.

Exposure is an effective intervention for avoidance (Bryant et al., 2014; Eisma et al., 2015; Rosner et al., 2011). Typically, this involves experimental exercises in the form of graded exposure to the feared situation or object, or flooding exercises to provide desensitization, accompanied by with affect monitoring and regulation techniques. Both graded exposure and flooding can be implemented through letter writing exercises, combined with the subsequent discussion in the therapy session. Writing to the deceased is exposure in and of itself—with every letter, the bereaved person must, at some level, accept that person to whom the letter is addressed cannot respond, because he or she is dead. Writing the letter is a confrontation with the reality of the loss.

Graded exposure can be achieved when writing a series of letters, addressing and approaching, little by little, an avoided topic. If the time of the death is the avoided topic, graded exposure can involve writing a series of letters describing experiences and events leading up to the death, followed by a letter addressing the time of death. Exposure in the form of flooding can be achieved by delving deep into a particularly difficult moment, for example, finding the deceased dead. This approach resembles the earlier describe WET method for PTSD (Sloan & Marx, 2019). The bereaved person can be instructed to describe that moment using as many details as possible, including sensory experiences, such as sight, sounds, smells, and texture, as well as feelings, reactions and thoughts. That moment can be repeatedly described in several letters, each time perhaps with a slightly different focus (e.g., what was felt, what was feared, and what was observed), thus revealing more detail and producing a rich, nuanced memory. In the process of doing so, the client should experience a decrease in affective intensity. Through processing the memory and discussing it with the therapist, the memory can become less emotionally charged, more nuanced and better integrated into the client’s narrative.

In conclusion, exposure in the form of letter writing can be a manageable way for some clients to confront otherwise avoided thoughts, feelings and situations. The letter writing activity gives the client the opportunity to prepare for and work with the challenging elements of therapy at home, which for some can be helpful, if not necessary.

Addressing Unfinished Business

In both the theoretical and clinical bereavement literature, ‘unfinished business,’ is discussed as a risk factor for complicated grief (Holland et al., 2014; Klingspon et al., 2015). It refers to incomplete, unexpressed and unresolved relational issues involving the deceased, and is often associated with emotional reactions such as regret, anger, guilt, or remorse (Holland, Klingspon, & Neimeyer, 2014). As a construct, unfinished business has been thought to relate to cognitive processes involving appraising the relationship as lacking closure or resolution (Holland et al., 2014; Klingspon et al., 2015). It has also been proposed that unfinished business could relate to the disruption in attachment, resulting in an intense and ruminative clinging to the lost relationship (Klingspon et al., 2015). Unresolved unfinished business can therefore become a barrier to the integration of and adjustment to the loss in the bereaved persons continued life.

Experiencing a sense of unfinished business following a death of a significan other is common, distressing, and associated with poorer bereavement outcome, and therefore often a focus in grief therapy (Holland et al., 2014, 2020; Klingspon et al., 2015). Examples of therapeutic tools used to address this include the empty chair technique, involving imaginary conversations with the deceased (Field & Horowitz, 1998; Paivio & Greenberg, 1995), and other exercises involving imaginary conversations, e.g., letter writing assignments (Boelen et al., 2013; Bryant et al., 2014; 2017; Rosner et al., 2011; Shear, 2017). It has been suggested, based on exploratory and confirmatory factor analyses, that unfinished business is made up of two related factors: ‘unresolved conflicts’, relating to unaddressed conflicts or indiscretions, and ‘unfulfilled wishes,’ having to do with unspoken affirmation or missed opportunities with the deceased (Holland et al., 2020).

Addressing unresolved issues and unfulfilled wishes, and the associated feelings, such as anger, regret, and guilt, can be difficult but necessary to come to terms with the loss. To that end, writing letters to the deceased can be a meaningful and effective vehicle for expressing thoughts and feelings related to both past conflicts and future missed opportunities. When composing letters about past conflictual and perhaps painful issues, the bereaved person may access and explore feelings associated with these situations in a controlled, manageable way (defined by the structure of composing a letter). Subsequently, discussing the letter, and what it brings up for the client, in the therapeutic setting, may bring relief, new interpretations of situations, and altered emotional reactions. The bereaved person may become able to see and place the conflict in a broader context, which includes that which has happened since the conflict, and who the bereaved person is now. Perhaps the bereaved person has become more mature and better able to understand and come to terms with what happened in the years prior. The client and therapist may look at the conflict from different perspectives, consider personal motivations and options relevant at the time, examine expectations of others and oneself, and discuss issues around responsibility. Through the process, the client may be able to work on acceptance of what cannot be changed and consider forgiveness (of the deceased and/or of the bereaved person him or herself), which may help alleviate some of the negative emotions and facilitate acceptance of the loss.

Working on unfinished business is perhaps particularly important when the bereaved person struggles with feelings of guilt due to past transgressions, conflicts, or decisions. When a person is dead, so is the opportunity to make up, apologize, or receive forgiveness. Struggling with feelings of guilt post-bereavement has been found to be associated with increased risk of developing complicated grief and depression (Li et al., 2019; Stroebe et al., 2007). Thus, assessing and addressing guilt by targeting unfinished business in the therapeutic context is relevant and may help preserve mental health. Working to address feelings of guilt, may be particularly important in the case of bereavement due to suicide, where that feeling is particularly prevalent (Camacho et al., 2020).

Some bereaved people struggle with unfinished business, in the form of unfulfilled wishes, because they feel they did not have the opportunity to say goodbye to the deceased the way they would have liked to. Writing a goodbye letter to the deceased can be helpful for some. The bereaved person can think about, structure, and express what he or she would like to have said. For some, this helps add a sense of closure which has been missing, making it possible to proceed with the grieving process. Another source of unfulfilled wishes has to do with broken dreams. The relationship has been cut short and hopes for a shared future are lost. In letters to the deceased about these future losses, the bereaved person can express thoughts and feelings related to the altered future without the deceased, and, in the process of doing so, work on accepting and coping with a new reality. For example, the bereaved person may write about the sense of loss and pain associated with not being able to share important milestones, such graduations, weddings, birthdays and holidays. Young adults who have lost a parent, may experience regret that the parent will not get to know them as adults, that they will not have the opportunity to give back to the parent or share becoming a parent him- or herself. Expressing and processing this through letters and in subsequent conversations with the therapist can be helpful.

Promoting Continuing Bonds

While writing letters to the deceased can offer the opportunity to work on closure and saying goodbye to the deceased as a physical presence in the bereaved person’s life, it can also help promote a continuing bond. It is broadly accepted within the field that maintaining a bond to the deceased, especially when it is a close attachment figure, is meaningful and helpful to many bereaved people (Klass et al., 1996; Worden, 2018). Writing to the deceased is a way to bring him or her within reach, enabling ongoing communication, albeit a symbolic one. The bereaved person is often able to imagine how the deceased would have responded and may even write this as part of the letter—for example, “I know, you would say that I should get on with my life.” Thus, the bereaved person can be instructed to write about problems but also how the deceased person would have been able to help. If the client imagines that the deceased would have responded with advice or encouragement, it can be reassuring. Consequently, the therapist can point out that the bereaved has internalized the deceased to some degree, and that he or she is still present within the bereaved person’s experience and life, although not in a physical sense. This can be solidified by encouraging the bereaved to write about situations where the deceased will be missed, and describe how the deceased will be “present,” for example, through rituals on special days (e.g., birthdays and holidays), in talking about the deceased (e.g., with grandchildren), sharing memories, creating a legacy and so on. Upon completion of therapy, the bereaved person may also find that continuing to write letters becomes a way to “share” important experiences and milestones with the deceased, thereby nurturing the continuing bond.

Working with Positive Memories

Bereavement is often associated with experiencing intrusive negative memories and images (Boelen & Huntjens, 2008). For example, a study found that bereaved people with PGD, were more likely to experience memories of negative treatment- and illness-related imagery and less likely to experience spontaneous positive imagery, compared to those with natural grief reactions (Smith et al., 2020). That is, bereaved people with PGD seem to have an attentional bias towards negative loss-related imagery (Maccallum & Bryant, 2011b). In addition, bereaved people with PGD report that they need to apply more effort to recall positive memories, compared to bereaved people without PGD (Smith et al., 2020). It is possible that the lack of spontaneous positive reminiscing might contribute to low mood and lack of psychological closeness to the deceased (Smith et al., 2020).

In addition to more frequent negative images and memories, studies have also found PGD to be associated with impaired memory specificity (Maccallum & Bryant, 2010), which in turn also has been found to correlate with difficulty imagining specific future events (Maccallum & Bryant, 2011b). Further, people with PGD are more likely to imagine future events in relation to their loss (Maccallum & Bryant, 2011b). Thus, it seems, bereaved people who experience a problematic grief reaction may struggle with negative memories and images that are emotionally laden but lack specificity, and that these memories impact current functioning and thoughts about the future.

Fortunately, it is possible to work with memories in therapy. For example, it is possible to increase positive memory specificity through CBT, which in turn can result in a reduction in grief symptoms (Maccallum & Bryant, 2011a). When working with memories, letter writing may be particularly helpful and meaningful. The assignment can be to recall and describe a memory (positive or negative) in as great a detail as possible, and in a sense share that memory with the deceased. When preparing the letter, the bereaved person tries to recall as much as possible and make the description as detailed and rich as possible. In the subsequent sharing and discussing of the letter and memory with the therapist, the bereaved person may recall even more detail, be able to view things from a different perspective, and perhaps come to attach new meaning to the memory. Exploring, elaborating, and perhaps reinterpreting the memory, and focusing on what thoughts and feelings that they elicit, can be healing, as self-awareness increases, and negative emotional responses may decrease.

It not uncommon for negative memories to dominate. However, with specific instruction to think and write about positive memories, these can be given more room in the bereaved person’s intrapsychic space, which can help balance the negative ones. In other words, this can help alleviate the attentional bias towards negative events, and recall of the past becomes more manageable, not just a source of pain.

Writing letters focusing on specific memories tends to make sense to bereaved clients. It is a circumscribed, concrete assignment. Writing positive memories provides a welcomed break from working on topics that tend to bring only painful and difficult emotions. However, writing about positive memories can also seem challenging at first, as the bereaved person fears not being able to recall much. What tends to happen, though, is that once they start to work on the letter, recall is easier than anticipated. Another benefit reported by clients is that once positive memories are written down, they will not be forgotten, which is a source of comfort to many.

Creating a Coherent Narrative Thorough Integration of Autobiographical Memories

It has been proposed that complicated grief is associated with insufficient elaboration and poor integration of autobiographical memories associated with the loss into the greater autobiographical network (Barbosa et al., 2014; Boelen et al., 2006, 2010; Maccallum & Bryant, 2011a, 2013). Others have suggested that there is a failure to update attachment-related memory and internal mental representations (Shear et al., 2007). As a result, the bereaved person experiences a mismatch between the reality and internal mental representation of the self and the world (Boelen et al., 2006) and of attachment-based internal representation of the deceased, who is still expected to be available to the bereaved (Shear et al., 2007). That is, the client fails to understand, on an experiential/psychological level, that the death is irreversible, and he or she continues to be shocked when confronted with the loss (Boelen et al., 2006).

Clients do not typically report that they experience problems with integration of their autobiographical memories, but they will note that they find the time around the death or during the course of illness to be confusing and unreal. They may even feel uncertain about the order in which things happened, and isolated intrusive memories repeatedly appear (Boelen et al., 2006; Maccallum & Bryant, 2010). That is, they lack a coherent narrative of what they have experienced associated with the death of their loved one, which can be associated with an ongoing painful yearning for the deceased (Gillies et al., 2014).

Narrative-based grief treatment methods have been developed (Neimeyer, 2005; Neimeyer et al., 2010; Peri et al., 2016). An example is narrative reconstruction therapy, where an integrative treatment intervention developed for PTSD has been adapted for PGD. In a pilot study, this treatment was found to be effective in reducing symptoms of PGD, depression and PTSD in participants with PGD (Elinger et al., 2021). It incorporates exposure and narration, integration of traumatic memories with other autobiographical memories, and subjective meaning-making (Peri et al., 2016). During 16 weekly sessions, the client works on creating a detailed, minute-by-minute description of an intruding memory that has been haunting the client. In the process of doing so, the client is instructed to describe thoughts, feelings, other sensations, and actions. The therapist writes down the memory. From week to week, the narrative is reread and built upon. The intervention is thought to promote or reveal new insight, hidden feelings, and facts in connection to the memory which previously had been lost from the client’s memory. All in all, the study suggested that working with bereaved people on organizing their experiences into a coherent narrative can be helpful.

Using letter writing can also be an effective way to work on establishing a coherent narrative. For example, the client can be instructed to write a series of letters, detailing experiences during the course of illness in chronological order. The client focuses on a limited number of experiences, addressing the most salient, difficult ones. Or, the bereaved person, for whom the moment of death is particularly distressing, could be instructed to write a series of letters, detailing days leading up to the day, the day of the death, and the day of funeral, in as great detail as possible. When discussing the letters in the therapy sessions, focus will be on the bereaved person’s past experiences but also on present feelings, thoughts and sensations. For some clients it is helpful to first create a timeline of salient events/experiences over the course of the illness, treatment, and death. In the case of a sudden death, the timeline will cover a much shorter time span, perhaps starting with the morning of the day of the death, to the death notification, through the day of the funeral. When writing a series of letters, addressing specific, salient, and important events, a coherent narrative is gradually established. In other words, using letter assignments can provide an opportunity to retell, (re)organize, and integrate memories related to the death into a coherent narrative, which then can be seen in the even greater context of the bereaved person’s life. In other words, the loss, becomes an integrated part of the bereaved person’s life.

Considerations When Using Letter Writing in a Clinical Context

Expressive writing in the form of letters may be a useful supplement to traditional grief therapy for several reasons. It may facilitate both the process and outcomes of psychotherapy as discussed above. It gives the clients the opportunity to work privately, controlling their own intervention dosage. It is low cost and easily implemented. Furthermore, expressive writing intervention has been shown to be feasible and tolerable in a variety of difficult situations, as seen in, for example, the WET program for persons with PTSD (Sloan et al., 2021), in the use of storytelling in newly bereaved caregivers (Barnato et al., 2017), in persons bereaved through drug-related deaths responding to writing prompts (Thatcher, 2021), and the brief “Writing for Recovery” program tested in bereaved Afghani adolescents refugees (Kalantari et al., 2012). Finally, although not expressively tested, using expressive writing in form of letters is feasible in the context of bereavement therapy, inferred by its repeated use across effective treatments for PGD (e.g., Boelen et al., 2013; Bryant et al., 2017).

However, using letter writing as a clinical tool has its limitations a well. For example, expressive writing may result in immediate distress and discomfort (Smyth, 1998). Thus, some clients may choose to stop and not complete the letter assignment, if they exceed their tolerance for emotional distress. Or they may not accept the assignment altogether. Indeed, in my experience, some clients are reluctant to accept the letter writing assignment at first, fearing that it will be too difficult and painful. Accordingly, it is important to assess the client’s motivation and willingness to confront difficult content and memories, as well as consider his/her ability to tolerate and manage emotional distress independently. Helping the clients identify ways to cope with emotional distress on their own, as well using positive reinforcement, that is, rewarding themselves afterwards by, for example, planning to do something nice for themselves after writing a difficult letter, can help increase motivation to complete the assignment. Some clients may have trouble understanding the value in writing letters to the deceased about upsetting experiences. Here it might be helpful to review some of the potential benefits discussed in this paper, depending upon the therapist’s reason for incorporating letter writing. Also, it might be helpful to encourage the clients to try it out, before deciding that it is not relevant for them. In my experience, initial resistance often gives way relatively quickly to an appreciation for letter writing as a way to process grief and connect with the deceased.

Practical considerations also warrant consideration when determining if letter writing might be a good tool to use with a particular client. For example, clients who have learning, cognitive or physical disabilities or literacy issues may find letter writing difficult and may lack motivation to engage in writing activities. Consequently, it should be considered if or how letter writing can be helpful. Perhaps rather than writing the letters, they can be dictated. Clients, who struggle with limited self-awareness and for whom reflecting on experiences is difficult, may also not benefit from writing assignments as described in this paper, and focusing on exploring clinical material through traditional in-session conversation may be best. Finally, in some situations, the client may lack the time, privacy at home, or the motivation to complete homework assignments. If the therapist is unable to help the client solve these problems, letter writing assignments are not feasible.

Conclusion

This paper has described how integrating letter writing in the context of grief therapy can play a helpful and meaningful role. It has been suggested that writing letters to the deceased can help facilitate many of the essential elements that make grief therapy effective, from promoting self-disclosure, addressing exposure to the avoided, through working on a continuing bond and a coherent narrative, and more. Working on confrontation with and acceptance of the loss is built in, as writing to a deceased person, who will not be able to respond in kind, is a form of exposure to the fact that the person has died. The absence of the deceased person in the physical world is made clear. However, at the same time, a psychological or spiritual connection seems possible, thus facilitating a continued relationship. In most situations, it is not difficult for the bereaved person to engage in this imaginative correspondence.

One might justifiably ask, why bother with letters? Why not just work on memories, confront what is avoided, address unfinished business, work on the continuing bond, and so on, through conversations in therapy? Certainly, for some writing letters may not be necessary, but for others, having the opportunity to think and write about important and difficult experiences, seems to bring a needed level of clarity, understanding, and organization to the clinical material. It facilitates the subsequent therapeutic process in the sessions with the therapist. Furthermore, for some, it seems to make this difficult work more manageable, as experiences can be addressed at the client’s discretion and pace, and in a mode of confrontation less intense and more tolerable, than during an on-the-spot, face-to-face conversation with the therapist. Finally, through the symbolic correspondence with the deceased, the deceased comes to play a significant role in the work. In my experience, this is often perceived as helpful and comforting to the bereaved.

Of course, letter writing is not a magic bullet. Grief therapy is still difficult, demanding of both the client and the therapist. Letter writing is but a tool, which can help facilitate the work, by providing structure, an entry into clinically important material and processes, and a meaningful way to engage the client in the therapeutic process between sessions. Other important elements such as psychoeducation, in vivo exposure experiments, affect regulation exercises, cognitive restructuring, and future goals, remain important elements to include.

In the literature, the effect of writing assignments in the context of bereavement has been inconclusive, failing to consistently show a positive outcome. Yet, writing assignments continue to be included in grief therapy protocols that effectively help bereaved persons with complicated grief. It is possible that examining the isolated effect of writing assignments in non-clinical populations and settings, and without the opportunity to share and process the content of the letters with a therapist simply does not capture what letter writing has to offer as a tool in a therapeutic context. In addition, the reason for, and benefits of, including letters in therapy may vary from person to person, making it hard to isolate and study the effect. For some, writing letters is necessary to make confrontation a bit less confrontational. Others benefit from the structured approach to working with and gaining access to clinical material. Others use letters to work on establishing a connection to the deceased or a meaningful coherent narrative. If one were to try to study and assess the unique contribution of letter writing as a clinical tool, the study would need to be designed to compare the effectiveness of a particular treatment protocol using letter writing to the same treatment protocol without using letters. It would be helpful to keep as many other variables constant as possible, such as the demographics of the bereaved, relation to the deceased, grief symptom intensity and presenting grief-related problems, primary presenting problem (e.g., avoidance of the reality of the loss; intrusive memories), circumstances of the loss, and so on, so that the treatment target would be as similar as possible, with the main variation being use of letter writing. That could help isolate and show the unique contribution of incorporating letters. However, given the complexity of grief responses, the individual needs of the bereaved, and the integrative nature of grief therapy (often applying a variety of tools and techniques) it may provide difficult to isolate and demonstrate the unique contribution of letter writing.

In conclusion, letter writing should be thought of as a tool in the clinician’s toolbox, which also include conversation, looking at photographs and mementos, using drawing and other creative expressive techniques, and so. However, in the context of grief therapy, letter writing may hold special significance with its salient focus on the relation to the deceased. Grief, in connection with the death of a significant other, takes it root in that lost relation, and having it be font and center in therapy is meaningful.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lene Holm Larsen

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