A pilot randomised controlled trial of metacognitive therapy for prolonged grief

State of the Science: Psychotherapeutic Interventions for Prolonged Grief Disorder

Prolonged grief disorder (PGD) is a distinct diagnostic entity that has recently garnered considerable attention as it describes an intense, enduring, distressing and disabling bereavement reaction experienced by a small minority of community-based mourners. In recent decades, research has exploded to address how best to treat PGD with different psychotherapeutic interventions. In this state-of-the-science review, the strength of the evidence will be discussed regarding common psychotherapeutic interventions used to treat grief. Specifically, we focus on the most commonly used interventions, cognitive behavioral (CB)-based therapies, bereavement and support groups, and brief contact interventions (BCIs), in an effort to summarize the relevant clinical takeaways of the current available research. A discussion of the use of these therapies in specific clinical populations is also included, with a focus on those traumatically bereaved, pediatric populations, communities of color, and underserved communities. Important foci and directions for future research are also discussed.

Exploring the journey of supporters in bereavement support groups: Experiences, sense-making, and social connections

This study aimed to explore facilitators' experiences in bereavement support groups as they relate to their experiences of personal loss. Semi-structured interviews were conducted with nine facilitators who had experienced such grief, and data were analyzed qualitatively using a modified grounded theory approach (M-GTA). The analysis revealed two categories and nine subcategories: (i) 'Experiences in group activities,' encompassing positive and negative experiences during activities, and (ii) 'Structuring of Meaning,' the process of deciphering for oneself in relation to one's experience of loss and life. These two categories interacted with each other, and it was important for facilitators to find meaning in their activities, loss experiences, and lives for the stable continuation of bereavement support group activities. These findings underscore the importance of facilitators following and supporting the sense-making process.

From loss to disorder: The influence of maladaptive coping on prolonged grief

Research indicates that post-bereavement coping strategies can be adaptive or maladaptive. Understanding which strategies lead to poorer outcomes is an important clinical and theoretical question with the potential to guide intervention. The Oxford Grief - Coping Strategies scale was developed from interviews with bereaved people with and without prolonged grief disorder (PGD) to assess the frequency of maladaptive cognitive and behavioural strategies after bereavement. Factorial and psychometric validity were assessed using exploratory and confirmatory factor analysis (N = 676). A three-wave cross-lagged panel model (N = 275) was used to assess the predictive validity of the tool in explaining symptoms of PGD. Results supported a four-factor solution (Avoidance, Proximity Seeking, Loss Rumination, Injustice Rumination) with good psychometric properties. The OG-CS predicted prospective symptoms of PGD in the short-term (6-12 months) and long term (12-18 months), controlling for baseline symptoms and autocorrelations. Subscale analyses demonstrated that the use of coping strategies predicted ICD-11 PGD in both the short-term and the long-term. However, avoidance was not predictive of outcomes early in the grieving process. At 6-12 months, avoidance predicted PGD at 12-18 months.

The meaning in loss protocol: A clinical trial of online grief therapy

For a minority of the bereaved, the loss of a significant other can trigger an overwhelming emotional reaction and impaired functioning across life domains, known as prolonged grief disorder (PGD). Hence, ongoing efforts have been made to refine existing treatments to increase their efficacy and to accommodate the idiosyncrasies of grief reactions. This study presents the results of an open clinical trial of the feasibility and effectiveness of the Meaning in Loss (MIL) protocol in an online format. The brief intervention of 12 to 16 sessions combines constructivist and narrative strategies to explore and work through impediments to meaning reconstruction in loss. The sample included 25 participants diagnosed with PGD who were treated by six therapists. Baseline and post-therapy comparisons showed a significant improvement in all clinical measures (grief symptomatology, depression and general distress) and an increase of meaning making regarding the loss. Meaning making was found to be a prospective mediator of symptomatic improvement in grief across the course of therapy. These findings suggest the effectiveness of the MIL protocol in decreasing grief specific and associated symptomatology and argue for the relevance of further controlled evaluations of its efficacy. Moreover, results confirm previous findings that meaning making is a relevant factor in the evolution of grief reactions, including in the context of psychotherapy.

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.

On the concept, taxonomy, and transculturality of disordered grief

The enduring question of whether grief can ever be pathological (and, if so, when) has been shrouding mental health and psychiatric care over the last few years. While this discussion extends beyond the confines of psychiatry to encompass contributions from diverse disciplines such as Anthropology, Sociology, and Philosophy, scrutiny has been mainly directed toward psychiatry for its purported inclination to pathologize grief-an unavoidable facet of the human experience. This critique has gained particular salience considering the formal inclusion of prolonged grief disorder (PGD) in the 11th edition of the International Classification of Diseases (ICD-11) and the subsequent Text Revision 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This study contends that the inclusion of prolonged grief disorder as a diagnostic entity may be excessively rooted in Western cultural perspectives and empirical data, neglecting the nuanced variations in the expression and interpretation of grief across different cultural contexts. The formalization of this disorder not only raises questions about its universality and validity but also poses challenges to transcultural psychiatry, due to poor representation in empirical research and increased risk of misdiagnosis. Additionally, it exacerbates the ongoing concerns related to normativism and the lack of genuine cultural relativism within the DSM. Furthermore, the passionate discussion surrounding the existence, or not, of disordered forms of grief may actually impede effective care for individuals genuinely grappling with pathological forms of grief. In light of these considerations, this study proposes that prolonged grief disorder should be approached as a diagnostic category with potential Western cultural bias until comprehensive cross-cultural studies, conducted in diverse settings, can either substantiate or refute its broader applicability. This recalibration is imperative for advancing a more inclusive and culturally sensitive understanding of grief within the field of psychiatry.

The integrated process model of loss and grief - An interprofessional understanding

Despite the vast developments in research on loss and grief, dominant grief models fall short in reflecting the comprehensive issues grieving persons are facing. Three causes seem to be at play: grief is usually understood to be connected to death and other types of loss are under-researched; the majority of research is done from the field of psychology and on pathological forms of grief, hardly integrating research from other disciplines; and the existential suffering related to grief is not recognized or insufficiently integrated in the dominant models. In this paper, we propose an integrated process model (IPM) of loss and grief, distinguishing five dimensions of grief: physical, emotional, cognitive, social, and spiritual. The integrated process model integrates therapies, tools, and models within different scientific theories and paradigms to connect disciplines and professions. The comprehensive and existential understanding of loss and grief has relevance for research, clinical settings and community support.

Effectiveness of a cognitive-behavioral group therapy for complicated grief in relatives of patients with cancer: A randomized clinical trial

INTRODUCTION

Complicated grief can affect a large number of individuals who have lost a relative due to cancer.

OBJECTIVES

To assess the efficacy of a cognitive-behavioral grief therapy (CBGT) group for complicated grief (CG) in those who have lost a relative due to cancer in comparison with a psychoeducational and emotional expression intervention group (PSDEEI).

METHODS

A randomized clinical trial was used, in which 249 relatives of deceased cancer patients with CG were randomly assigned to CBGT or PSDEEI. Complicated grief (Inventory of Complicated Grief [ICG]), depression (Beck Depression Inventory [BDI-II]), hopelessness (Beck Hopelessness Scale [BHS]), anxiety (Beck Anxiety Inventory [BAI]) symptoms, and general health (Goldberg's General Health Questionnaire [GHQ28]) were assessed at pretreatment, posttreatment, and follow-up at 6 and 12 months.

RESULTS

The CBGT group improved significantly (p < 0.001), with the scores in ICG, BDI-II, BAI, BHS, and GHQ28 (p < 0.001) being higher than those for the PSDEEI group in each of the assessed moments, with high effect sizes: ICG (η2 = 0.16), BDI (η2 = 0.10), BAI (η2 = 0.06), BHS (η2 = 0.21), and GHQ28 (η2 = 0.21). At the 12-month follow-up, the number of cases of CG decreased by 81.1% for the CBGT group vs. 31.7% in the PSDEEI group.

SIGNIFICANCE OF RESULTS

The CBGT treatment was effective for CG, depression, anxiety, and hopelessness symptoms and for mental health and was superior to the PSDEEI treatment.

Reciprocal Relations of Worry, Rumination, and Psychopathology Symptoms After Loss: A Prospective Cohort Study

Bereavement can precipitate symptoms of depression, prolonged grief disorder, and posttraumatic stress disorder. Targeting repetitive negative thought (i.e., worry, rumination) in treatment may help reduce post-loss psychopathology. Yet, evidence on longitudinal associations of depressive rumination and worry with post-loss psychopathology symptoms has been mixed and the directions of effects are still unclear. Recently bereaved adults (78% female) completed questionnaires assessing depressive rumination (brooding), worry, and depression, prolonged grief and posttraumatic stress symptoms 11 times in 1.5 month intervals. We applied random-intercept cross-lagged panel models (RICLPMs) to examine reciprocal within-person associations between worry and psychopathology symptoms, between rumination and these symptoms, and between worry and rumination. Main findings were that worry showed reciprocal relationships with psychopathology symptoms (although worry did not consistently predict prolonged grief symptoms). Depressive rumination was predicted by psychopathology symptoms, but not vice versa. Worry showed reciprocal relations with depressive rumination. Findings suggest that worry may be part of a downward spiral, enhancing psychopathology symptoms following loss, whereas depressive rumination is solely a consequence of such symptoms.

The Scope of Metacognitive Therapy in the Treatment of Psychiatric Disorders

Metacognitive therapy (MCT) is a novel and promising transdiagnostic psychotherapy intervention based on the Self-Regulatory Executive Function model of conceptualizing emotional disorders. It was developed by Adrian Wells in 2009. Its therapeutic response occurs by reducing dysfunctional metacognitive beliefs regarding worry and rumination, often seen in patients with psychiatric disorders. Since its inception, it has been increasingly applied to a wide spectrum of psychiatric illnesses, but mainly focusing on mood and anxiety disorders. To our knowledge, no study has detailed its existing therapeutic scope in psychiatry. In this comprehensive narrative review, we describe the various psychiatric illnesses in which MCT has been used, the advantages of MCT, and the limitations of the MCT research. In addition, we propose some solutions to systematically examine its place in psychiatry. We encountered its potential role in treating trauma and stress-related disorders, obsessive-compulsive spectrum disorders, personality disorders, psychotic disorders, substance use disorders, and sexual disorders.

Bereavement during the COVID-19 Pandemic: Impact on Coping Strategies and Mental Health

The COVID-19 coronavirus has caused 5.4 million deaths worldwide, including over 800,000 deaths in the United States (as of December 2021). In addition to these staggering statistics, an even greater number of individuals have died from other causes during the COVID-19 pandemic. As a result, a large portion of the global population has faced bereavement during the COVID-19 pandemic and resulting quarantine. The often rapid and unexpected nature of COVID-19 deaths and the presence of pandemic-related stressors and living restrictions make it more difficult for individuals bereaved during the pandemic to implement effective strategies for coping with the loss compared to non-pandemic periods. Quarantine-related constraints (e.g., social distancing, availability of and access to resources) impede coping strategies that have been found to be adaptive after a loss, such as supportive (e.g., seeking emotional and instrumental support) and active (e.g., problem-focused and cognitive reframing) coping, and they augment avoidant strategies (e.g., substance use, denial, and isolation) that have been found to be maladaptive. Poorer mental health outcomes (including prolonged grief disorder; PGD) have been associated with less healthy coping. This article reviews research findings regarding bereavement during the COVID-19 pandemic, discusses the effects of pandemic-related stressors on bereavement coping strategies, and proposes how different types of coping during the pandemic may account for the poorer mental health outcomes described in recent reports. Interventions for promoting adaptive coping strategies and minimizing maladaptive coping strategies are also outlined.

A Longitudinal Examination of Quality of Life of Older Adults with Complicated Grief Receiving Accelerated Resolution Therapy

Objective: To examine the effect of Accelerated Resolution Therapy (ART) on the quality of life (QOL) of older adults with complicated grief (CG) over time. Design: Subanalysis of a randomized controlled trial. Setting/Subject: Older adult, former caregivers were recruited from a large hospice in the southeastern United States to be treated with ART for CG. Measurement: The CDC Health-Related Quality of Life (HRQOL) Healthy Days Module was administered pre-, post-, and eight weeks after therapy. Results: The subsample consisted of 27 older adults. A multilevel model indicated a statistically significant, negative difference of 8.21 (improvement) in QOL scores for each period of data collection (β = -8.21, t = 4.02, p < 0.001). Both the intervention (11%, p = 0.013) and time (7.8%, growth curve p = 0.014) contributed significantly. Conclusion: There was a significant large effect of ART on CG. This study supports concurrent improved patient-related outcome-QOL.

Rumination, worry and negative and positive affect in prolonged grief: A daily diary study

After bereavement, a significant minority experiences severe, persistent, and disabling grief, termed prolonged grief or complicated grief. Prolonged grief treatments may be enhanced by improving understanding of malleable risk factors in post‐loss psychological adaptation. Repetitive negative thought (e.g., rumination, worry) constitutes such a risk factor. Rumination and worry are both theorized to be maladaptive through interrelations with affect, yet this assumption has not been systematically investigated in the bereaved. We aimed to fill this gap in knowledge with a baseline survey and 10‐day daily diary investigation among a bereaved sample. Survey between‐subject analyses (N = 113) demonstrated that trait rumination and worry, trait negative affect and prolonged grief symptoms are positively related to each other and negatively related with trait positive affect. Within‐subject multilevel analyses of diaries (N = 62) demonstrated that trait rumination and trait worry relate positively to daily negative affect and negatively to daily positive affect. Daily rumination and worry showed similar relationships with daily negative and positive affect. A stronger relationship emerged between daily rumination and daily negative affect in people with higher prolonged grief symptom levels. Findings consistently support interrelations between repetitive negative thought, affect, and prolonged grief symptoms. Rumination appears particularly detrimental in people with severe grief reactions. Results align with research demonstrating the effectiveness of targeting repetitive negative thought in prolonged grief treatments. Additionally, our study demonstrates the potential feasibility and usefulness of using daily diaries to study behaviours of relevance to post‐loss adaptation in everyday life.

Upward and Downward Counterfactual Thought After Loss: A Multiwave Controlled Longitudinal Study

Counterfactual thoughts, mental simulations about how a situation may have turned out differently (i.e., "if only …, then …"), can reduce mental health after stressful life-events. However, how specific counterfactual thought types relate to post-loss mental health problems is unclear. We hypothesized that self-referenced upward counterfactuals (i.e., "If only I had done …, then the current situation would be better") may serve as cognitive avoidance, thereby perpetuating loss-related distress. Conversely, downward counterfactuals (i.e., "If … had happened, then the current situation could have been [even] worse") may facilitate benefit finding, thereby reducing distress. In a longitudinal survey, self-referent, other-referent, and nonreferent upward counterfactuals, and nonreferent downward counterfactuals were assessed at baseline. Prolonged grief and depression symptoms were assessed at baseline, and 6- and 12-month follow-ups. Multiple regression analyses assessed associations between counterfactual thoughts and symptom levels in 65 recently bereaved people who generated counterfactual thoughts about the loss-event. Moderator analyses assessed the unicity of significant effects in the previous step, by comparing these effects in 59 people generating loss-related counterfactuals with those in 59 propensity-score matched participants generating counterfactuals about other negative life-events. Multivariate analyses showed that nonreferent upward counterfactuals were uniquely strongly positively associated with prolonged grief and depression symptoms concurrently. Self-referent upward counterfactuals were uniquely positively associated with prolonged grief and depression symptoms longitudinally. Moderator analyses confirmed that thinking about how one's (in)actions could prevent a death uniquely exacerbated prolonged grief and depression severity. Prolonged grief treatment may be improved by targeting self-blame and guilt.

Mindfulness-Based Compassion Training for Health Professionals Providing End-of-Life Care: Impact, Feasibility, and Acceptability

Background: Health professionals who care for patients and their families at the end of life (EOL) may experience gratitude, and enhanced spirituality and meaning in life, yet they are also at increased risk of psychological distress, compassion fatigue, and occupational burnout given the stressors they encounter in their work. Objectives: This research evaluated the feasibility and acceptability of a novel six-week mindfulness-based compassion training intervention, which was tailored to health professionals involved in EOL care ("MBCT4HP"), and explored its impact on levels of psychological distress, compassion fatigue, compassion satisfaction, occupational burnout, self-compassion, and mindfulness. Design: We adopted an observational, repeated measures pilot study. Setting/Subjects: Thirty-one health professionals participated. The intervention comprised six, weekly sessions (totaling seven hours) designed to foster compassion for self and others, including formal and informal compassion and mindfulness practices, daily home practice, and a reflective experiential pedagogy. Measurements: Validated outcome measures for anxiety, depression, and stress; compassion satisfaction, compassion fatigue (burnout, secondary traumatic stress); occupational burnout (emotional exhaustion, personal accomplishment, and depersonalization), self-compassion, and mindfulness were administered at baseline, end of intervention, and eight weeks postintervention. The feasibility and acceptability of the intervention was assessed using attendance records, home practice logs, and self-report satisfaction items. Descriptive statistics and Generalized Linear Mixed Models were used to analyze the data. Results: Participants reported that the sessions were useful, relevant, easy to understand, and that they gave them sufficient knowledge to implement the strategies learned. Levels of anxiety, compassion fatigue (burnout only), and emotional exhaustion decreased over time with some decay in effects at follow up, and levels of compassion satisfaction and self-compassion increased with time. Conclusions: The intervention was feasible and acceptable to health professionals involved in EOL care and had a positive impact on levels of anxiety, compassion fatigue (burnout), emotional exhaustion, compassion satisfaction, and self-compassion.

A Systematic Review of Treatment Options for Grieving Older Adults

Purpose of review

a)The purpose of this systematic review was to characterize the studies published on grief interventions for bereaved older adults in the last 5 years. Grief intervention studies were included that exclusively focused on older adults as well as those that included older adults in their samples, in order to summarize the most up-to-date treatment options available for bereaved older adults.

Recent findings

b)Twenty-four articles that investigated grief interventions in older adults were identified. Generally, findings suggest viable treatment approaches for bereaved older adults are those incorporating behavioral activation and guidance on restoration-oriented coping. However, similar to studies of broader adult populations, grief interventions had small effects on grief-related symptoms in older adults. Few studies examined age as a moderator of treatment effects. Studies varied greatly by study design, sample size, and outcomes measured, which all likely impacted the efficacy of results.

Summary

c)This review suggests that, while there has been a growing focus on older adults, who have unique vulnerabilities in bereavement, the evidence-base of efficacious interventions for this population is limited. Given the need for specialized bereavement support for older adults will increase in the coming years, future research should prioritize rigorous investigations of grief treatment options leveraging technology to increase access and incorporate techniques that enhance engagement in life and connectedness for this vulnerable population.

Effects of bereavement groups-a systematic review and meta-analysis

This review summarizes the evidence of bereavement groups for symptoms of grief and depression. The literature search using Web of Science, EBSCO, PubMed, CINAHL, and MEDLINE yielded 14 studies (N = 1519) meeting the inclusion criteria (i.e., randomized-controlled trials, bereaved adults, bereavement group, validated measures). Overall, bereavement groups were marginally more effective than control groups post-treatment (gG = 0.33, gD = 0.22) but not at follow-up. Although tertiary interventions yielded larger effect sizes than secondary interventions, the difference was not significant. The results imply that the evidence for bereavement groups is weak, although the large heterogeneity of concepts for intervention and control groups limits the generalizability.

How thinking hurts: Rumination, worry, and avoidance processes in adjustment to bereavement

Repetitive negative thought plays an important role in the maintenance of mental health problems following bereavement. To date, bereavement researchers have primarily focused on rumination (i.e., repetitive thought about negative events and/or negative emotions), yet the interest in worry (i.e., repetitive thought about uncertain future events) is increasing. Both cognitive processes potentially lead to poorer adaptation to bereavement by contributing to loss‐related avoidance and behavioural avoidance of activities. The current study aims to establish the differential associations of rumination and worry with symptoms of depression and prolonged grief and clarify if avoidance processes mediate the associations of rumination and worry with symptom levels. Four hundred seventy‐four recently bereaved adults (82% female) filled out questionnaires assessing rumination, worry, loss‐related and behavioural avoidance, and depression and prolonged grief symptoms. Rumination and worry were both uniquely associated with depression and prolonged grief symptoms. Compared with worry, rumination related more strongly to prolonged grief symptoms, whereas correlations of both cognitive styles with depression symptoms did not differ. Loss‐related avoidance and behavioural avoidance partially mediated the associations of rumination and worry with prolonged grief symptoms. Behavioural avoidance partially mediated the associations of rumination and worry with depression symptoms. Findings suggest that exposure and behavioural activation may be effective interventions to reduce repetitive thinking and psychopathology after bereavement.