Pilot study on traumatic grief treatment program for Japanese women bereaved by violent death

A case report to understand the use of an evidence-based approach of prolonged grief therapy in Chinese culture

Prolonged grief disorder (PGD) is a new diagnosis that may cause significant functional impairment. Prolonged grief therapy (PGT) is a manualized 16-session intervention, whose efficacy has been demonstrated in studies primarily from Western cultures. The current report aimed to present a case to illustrate the use of PGT in Chinese culture. The client was a bereaved adult suffering from PGD after the death of her mother ten years ago. Additionally, she lost her father three months ago. Questionnaires were completed before and after treatment. In-depth interview was conducted at a 3-month follow-up. The client's scores for grief, functional impairment, grief-related beliefs and avoidance, depression and insomnia all decreased substantially after treatment. The follow-up feedbacks indicated that the beneficial effects of PGT persisted in the client's life. This case report provides preliminary evidence that bereaved people in China could benefit greatly from PGT, with minimal cultural adaptation.

Interventions for adult survivors of intrafamilial homicide: A review of the literature

Individuals bereaved by intrafamilial homicide, in which the perpetrator and decedent were both members of the same family, experience an elevated risk for risk for mental health complications. Given the contextual complexity of intrafamilial homicide (IFH) and the negative sequalae this form of loss can engender, psychological interventions may assist survivors with adjustment on a number of fronts. This scoping review therefore addresses an important knowledge gap by summarizing the limited information on interventions specific to intrafamilial homicide survivors. Results failed to identify interventions specific to IFH bereavement, though interventions that may be deemed appropriate are highlighted and described. As such, this scoping review provides a practical synthesis of evidence-based and evidence-informed psychological interventions for traumatic loss that are applicable to and may hold promise for this vulnerable population. Recommendations for future research and best practices with intrafamilial homicide survivors are also discussed.

Evaluations of Funerals and Health Trajectories in the Second Year After Bereavement-The Ongoing Japan National Survey

Our nationwide postal survey analyzing 190 responses from Japanese bereaved who had responded a year earlier found that funeral dissatisfaction rose during the second year after the funeral. Controverting previous research advocating participation in funeral planning, elderly bereaved spouses forced to decide about and/or pay for the funeral showed elevated grief as much as 2 years later. While not reaching levels diagnosed as prolonged, traumatic, or complicated grief, nevertheless one out of three of our bereaved sample showed continuing daily symptoms of grief from 14 to 24 months after their bereavement, with continued or increasing use of tranquillizers or antidepressants. The medical and pharmaceutical costs incurred by mourners more than a year after bereavement warrant further research into what factors improve or exacerbate the health of grieving bereaved, not limited to a single year after the bereavement.

Psychological Interventions for Individuals Bereaved by Homicide: A Systematic Review

Research has demonstrated that approximately 45-50% of individuals show healthy levels of psychological and physical functioning in the first 12 months post-loss. Homicidal bereavement (loss due to murder or manslaughter) does not appear to follow this pattern. Homicide-related mental health difficulties are a serious problem worldwide, displaying high rates of lifetime incidence, high chronicity, and role impairment. Individuals are at increased risk to develop symptoms of post-traumatic stress disorder (PTSD), complicated grief (CG), and depression. Nevertheless, a systematic review specifically on the efficacy of psychological interventions following homicidal loss has not yet been conducted. The current systematic review (registered via PROSPERO) aimed to review the psychological interventions available and report their effectiveness. Of 77 records, 7 met predefined inclusion criteria. Studies presented different methodologies, tested different clinical models, and treatment conditions. Thus, a narrative systematic review was conducted. Studies included manualized interventions to deliver 1:1 and group sessions. Cognitive behavioral therapy, restorative retelling, and eye movement desensitization and reprocessing were the main models used together with psychoeducational elements about trauma and grief responses. Overall, symptoms of PTSD, CG, and depression decreased significantly postintervention. Sustained improvements were reported for PTSD and depressive symptoms at the follow-up measurements. Mixed results were found regarding how individual (age, gender) and external factors (time since loss, relationship with the deceased) impact on symptom progression. As a result of differences in methodologies, categorization of therapies, methodological differences, and small sample sizes, important questions remain unanswered. Further randomized controlled trials and expert consensus could be considered.

Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice

In the United States alone, about 10 million persons are newly bereaved each year. Most do not require professional intervention or treatment, but many can benefit from targeted support. However, a significant minority of bereaved persons experience intense, prolonged and disabling grief symptoms associated with considerable morbidity and mortality (aka, "Complicated Grief"). Individuals with Complicated Grief require more formal interventions. In this article, we describe a compassionate and evidence-based approach to bereavement-care that can be provided in varied mental health settings. For individuals struggling with acute grief, clinicians can help by providing recognition and acceptance of the grief, eliciting and compassionately listening to their narratives of their relationship with the deceased and the death, and regularly "checking in" regarding their grief experiences. For bereaved persons who are experiencing Complicated Grief, we recommend an evidence-based approach to bereavement-care, complicated grief therapy (CGT), that involves helping the individual accept and cope with the loss while simultaneously assisting them with adaptation to life without the deceased. We describe ways of implementing CGT's seven core themes: (1) understanding and accepting grief, (2) managing painful emotions, (3) planning for a meaningful future, (4) strengthening ongoing relationships, (5) telling the story of the death, (6) learning to live with reminders, and (7) establishing an enduring connection with memories of the person who died. This work can be done in a variety of settings, taking into consideration the needs of the patient, the limitations of the setting, and the skills and experiences of each clinician.

Ritual in Therapy for Prolonged Grief: A Scoping Review of Ritual Elements in Evidence-Informed Grief Interventions

The aim of this article of to analyze ritual in evidence-informed treatments for prolonged and traumatic grief. A scoping review is conducted in order to give an overview of existing literature on ritual and symbolic interventions in grief therapies for prolonged grief and the type of evidence supporting these interventions. The 22 studies reported in this review reveal a variety of ritual elements ranging from symbolic expression and interaction, writing assignments, dialogue with the deceased or an imaginary person, to farewell ceremonies at the end of the treatment. The interventions are studied within different populations (e.g., bereaved spouses, perinatal loss, grief after violent death, and genocide). Almost all studies show significant effects of the grief treatment, trauma and related symptoms. However, the effects are mostly measured for the entire treatment and not separately for the ritual intervention. In the discussion we focus on the role of ritual and culture in prolonged grief treatment.

A Research Literature Review to Determine How Bereavement Programs Are Evaluated

A review of all 44 research reports published between 2000 and 2018 on bereavement program evaluation was undertaken to identify evaluation methods and assess their apparent efficacy. Bereavement program evaluations varied considerably, with multiple data collection methods per study common (61.4%) over single methods (38.6%). Among these evaluation methods, a self-devised questionnaire was most often used (59.1%), followed by qualitative interviewing (36.4%), and the use of 1 or more of 35 data collection instruments such as grief inventories or depression scales (40.9%). Evaluative data were usually only collected once (77.3%), typically around program completion. Formal bereavement program evaluation appears to be ad hoc and sporadic, and potentially unlikely to provide the type and quality of information needed to retain, improve, expand, or abandon programs. Evaluation method developments including evaluation standards are needed to ensure recipients and others benefit as expected from bereavement programs.

Concurrent Treatment for PTSD and Prolonged Grief Disorder: Review of Outcomes for Exposure- and Nonexposure-Based Treatments

This review gives an overview of treatments used to concurrently reduce symptoms of posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD). For purposes of this review, emphasis is placed on locating and comparing literature on exposure- and nonexposure-based treatments. Across 14 studies, the overall findings suggest that treatments are generally effective in treating PTSD and PGD concurrently and that treatments incorporating exposure-based components performed similarly to those without exposure-based components. However, methodological limitations preclude the ability to draw firm conclusions about the added impact of exposure-based components in traumatic grief treatment. Future directions for research on concurrent treatments for PTSD and PGD are discussed.

Grief intensity, coping and psychological health among family members and friends following a terrorist attack

This study investigates the association of psychological health with grief intensity and coping style among family members and friends of terror victims. The data was collected from 164 bereaved individuals, on average, 18 months after the bombings occurred. The results demonstrated the significant role of problem-focused social support, and religious coping in dealing with grief intensity and contributing to the psychological health. The findings may be of considerable importance in therapeutic situations by providing direction for coping with both the effects of traumatic event and a traumatic loss, and for maintaining emotional stability through reworking relationships with the deceased.

Self-perception of adaptation among homicidally bereaved individuals following a psychoeducational intervention: a UK longitudinal qualitative study

OBJECTIVE

Research on homicidal bereavement has focused on postloss impact and coping. Less is known about how individuals perceive their adjustment posthomicide. Adverse experiences are likely to leave individuals with an increased risk of developing severe psychological difficulties, such as depression, Post-traumatic stress (PTSD), anxiety and complicated grief. This study aimed to explore how individuals perceive their change and progression posthomicide and post-psychoeducational intervention.

DESIGN

Semistructured qualitative interviews were conducted both as part of a prospective study and retrospectively to allow for a longer follow-up period.

SETTING

Homicidally bereaved individuals who participated in a residential psychoeducational intervention offered by a national charity (Escaping Victimhood (EV)).

PARTICIPANTS

Twenty-nine individuals (mainly females) took part: 14 as part of a 6-9-month follow-up (short-term trajectory group (STG) individuals-mean age 45.25) and 15 individuals (long-term trajectory group (LTG) individuals-mean age 48.50), retrospectively, 2 to 5 years postintervention.

RESULTS

Interviews were analysed using an inductive Thematic Analysis method. Three main themes and nine subthemes emerged, and applied to both groups, as follows: (1) actual changes perceived by the participants (increased understanding, improved coping strategies and positive self-change), (2) barriers to recovery (severe psychological difficulties over time, need for further support, reminders and close relationships with both victim and perpetrator), and finally perceived future progression (living day by day, hope and hopelessness). The only significant differences between the two groups related to the reported self-growth among LTG individuals and the perceived increased informal support among STG individuals by keeping in touch in other EV participants.

CONCLUSION

This unique study provides insight into how homicidally bereaved individuals perceive their bereavement paths and helped to identify elements that appear to contribute for their adjustment. Importantly, it has highlighted that positive changes can also be an outcome.

Treating complicated grief and posttraumatic stress in homicidally bereaved individuals: A randomized controlled trial

Homicidally bereaved individuals may experience symptoms of Complicated Grief (CG) and Posttraumatic Stress Disorder (PTSD). This Randomized Controlled Trial examined the effectiveness of an 8-session treatment encompassing Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) to reduce self-rated CG and PTSD symptoms in 85 Dutch adult homicidally bereaved men and women. We compared changes in symptoms of CG (assessed using the Inventory of Complicated Grief) and PTSD (assessed using the Impact of Event Scale) between an intervention group and a waitlist control group. The treatment was effective in reducing CG and PTSD symptoms, from pretreatment to posttreatment. It can be concluded that EMDR and CBT seem promising treatments for homicidally bereaved individuals for both men and women, and regardless of the time since the loss. Further research is needed to examine whether a combined treatment of EMDR and CBT together is of added value in situations where grief and trauma are intertwined over offering only one of the two treatment modalities.

A scoping review of bereavement service outcomes

OBJECTIVE

This scoping literature review, through finding and assessing researched bereavement service outcomes, sought to determine the state of bereavement services evaluation, to catalogue service types, and to identify which service or services, if any, demonstrate clear evidence of effectiveness.

METHOD

Our methods included: (1) a literature search for published English-language research articles from 2005-2015; (2) critical appraisal of articles to identify findings; (3) compilation of findings; and (4) determination of the relevance of our findings.

RESULTS

Some 38 papers were found, and all were retained to identify the outcomes researched and research findings. Many different outcomes were studied in the 18 quantitative, 11 qualitative, and 9 mixed-methods investigations undertaken worldwide. Ten studies focused on level of grief, six on stress/distress level, six on grief knowledge, six on level of depression, and five on somatization or physical symptoms. Most commonly, a group of bereavement services was evaluated as a whole, followed by group therapy, individual counseling, written information, and other less common services. No group of services or individual service was determined to yield clear and convincing evidence of effectiveness. Regardless, all but one service were shown to have value-most often related to gaining grief information and/or emotional support. Until high-quality research studies have repeatedly revealed evidence of effectiveness, it is possible that the positive outcomes of bereavement services will be largely based on bereaved people receiving helpful educational information and emotional support from organizations and people prepared to help them.

SIGNIFICANCE OF RESULTS

This project outlines existing bereavement service types and the state of science in relation to determination of outcomes. It offers suggestions to advance the state of science to validate or refine bereavement services. It brings to light the issue that bereavement service outcomes need to be carefully researched so that evidence can drive service refinement and expansion. It also highlights the importance of effective bereavement services.

Assessment and associated features of prolonged grief disorder among Chinese bereaved individuals

BACKGROUND

Most research on the assessment and characteristics of prolonged grief disorder (PGD) has been conducted in Western bereaved samples. Limited information about PGD in Chinese samples exists. This study aims to validate the Chinese version of the Inventory of Complicated grief (ICG), examine the distinctiveness of PGD symptoms from symptoms of bereavement-related depression and anxiety, and explore the prevalence of PGD in a Chinese sample.

METHODS

Responses from 1358 bereaved Chinese adults were collected through an on-line survey. They completed the Chinese version of ICG and a questionnaire measuring depression and anxiety symptoms.

RESULTS

The findings indicate that Chinese ICG has sound validity and high internal consistency. The ICG cut-off score for PGD "caseness"in this large Chinese sample was 48. The distinctiveness of PGD symptoms from those of depression and anxiety was supported by the results of the confirmatory factor analysis and the fact that PGD occurred in isolation in the studied sample. The prevalence of PGD was13.9%.

CONCLUSION

ICG is a valid instrument for use in the Chinese context. Several key characteristics of PGD in Chinese, either different from or comparable to findings in Western samples, may stimulate further research and clinical interest in the concept by providing empirical evidence from an large and influential Eastern country.

Interventions for posttraumatic stress disorder in psychiatric practice across Europe: a trainees' perspective

BACKGROUND

With an annual prevalence of 0.9-2.6%, posttraumatic stress disorder (PTSD) is very common in clinical practice across Europe. Despite the fact that evidence-based interventions have been developed, there is no evidence on their implementation in clinical practice and in national psychiatric training programmes.

OBJECTIVE AND METHOD

The Early Career Psychiatrists Committee of the European Psychiatric Association conducted a survey in 23 European countries to explore implementation of evidence-based interventions for PTSD and training options.

RESULTS

The findings indicate that pharmacotherapy was available in the majority of the participating countries (n=19, 82.8%). However, psychological interventions were much less widespread. For example, psychoeducation was widely available in 52% of the countries (n=12), cognitive-behavioural therapy in 26.2% (n=6), and specific trauma-focused techniques were rarely available. Training on PTSD was part of the official training in 13 countries (56.5%), predominantly in the form of theoretical seminars.

CONCLUSIONS

Overall, this survey indicates that the treatment for PTSD is largely focused on pharmacotherapy, with psychological evidence-based interventions poorly available, especially outside specialized centres. Poor implementation is linked to the lack of official training in evidence-based interventions for psychiatric trainees across Europe.

Distinctiveness of prolonged grief disorder symptoms among survivors of the Great East Japan Earthquake and Tsunami

Prolonged Grief Disorder (PGD) has been proposed for diagnostic classification as an independent psychiatric disorder. Previous research has investigated it in relation to other axis I disorders in order to determine whether it could be considered an independent nosological entity. The distinctiveness of this condition was apparent in cases of ordinary bereavement and in those following human-made disasters. However, this disorder may be expanded to include bereavement resulting from natural disasters. The present study aims to explore the differences between this disorder and posttraumatic stress disorder or major depressive disorder as experienced after the Great East Japan Earthquake and Tsunami. The subjects were 82 hospital workers. Each type of disorder was assessed by means of the Inventory of Complicated Grief, the Impact of Event Scale-Revised, and the Center for Epidemiological Studies Depression Scale. Exploratory factor analysis showed 3 dimensions, with PGD items independently clustering in the same dimension. Our findings support the uniqueness of PGD even in a post-natural disaster situation in a non-Western culture and warrant grief intervention for high-risk bereaved survivors.

Bereavement and complicated grief

Bereavement is a common experience in adults aged 60 and older. Loss of a loved one usually leads to acute grief characterized by yearning and longing, decreased interest in ongoing activities, and frequent thoughts of the deceased. For most, acute grief naturally evolves into a state of integrated grief, where the bereaved is able to reengage with everyday activities and find interest or pleasure. About 7 % of bereaved older adults, however, will develop the mental health condition of Complicated Grief (CG). In CG, the movement from acute to integrated grief is derailed, and grief symptoms remain severe and impairing. This article reviews recent publications on the diagnosis of CG, risk factors for the condition and evidenced-based treatments for CG. Greater attention to CG detection and treatment in older adults is needed.

Complicated grief therapy as a new treatment approach

Complicated grief therapy (CGT) is a relatively new psychotherapy model designed to address symptoms of complicated grief. Drawn from attachment theory and with roots in both interpersonal therapy (IPT) and cognitive-behavioral therapy, CGT includes techniques similar to prolonged exposure (repeatedly telling the story of the death and in vivo exposure activities). The treatment also involves focusing on personal goals and relationships. CGT has been demonstrated to be effective in a trial in which participants with complicated grief were randomly assigned to CGT or IPT; individuals receiving CGT responded more quickly and were more likely to respond overall (51% vs 28%). This article briefly summarizes the conceptual underpinnings of CGT, discusses the empirical evidence for its efficacy, describes its techniques, and presents a case example of a client treated in a 16-session manualized CGT protocol. The article concludes with a description of future research directions for CGT.

Complicated grief in those bereaved by violent death: the effects of post-traumatic stress disorder on complicated grief

Violent death, such as homicide, accident, and suicide, is sudden, unexpected, and caused by intentional power, The prevalence of complicated grief among those bereaved by violent death is 12.5% to 78.0%. The factors affecting this prevalence rate are considered to be comorbid mental disorders, lack of readiness for the death, difficulty in making sense of the death, high level of negative appraisal about the self and others, and various social stressors. Post-traumatic stress disorder is, in particular, considered to contribute to the development of complicated grief by suppressing function of the medial prefrontal cortex and the anterior cingulate cortex, which works at facilitating the normal mourning process. An understanding of the mechanism and biological basis of complicated grief by violent death will be helpful in developing effective preventive intervention and treatment.