Treatment of complicated grief

The prevalence of prolonged grief disorder (PGD) after the natural disasters: A systematic review and meta-analysis

Objective

The failure to detect PDG and lack of providing essential interventions accordingly can disrupt the lives of survivors of natural disasters years after the death of their loved ones. The present study aims to investigate PGD after natural disasters using a systematic review and meta-analysis.

Study design

This study was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

Methods

With the focus on the prevalence of PGD after natural disasters, studies conducted until the end of 2021 were collected without a time limit. To do this, reputable databases such as PubMed, Web of Science, Scopus, Embase, Google Scholar, and Science Direct were used. The random effects model was used to perform a meta-analysis of the studies. To check the heterogeneity between the studies, the I2 index was used. The publication bias of the study was evaluated using Begg's test. Data were analyzed using the STATA software.

Results

Primarily, 2566 studies were collected based on the initial search, from which 12 final studies were entered into the analysis. The results showed that the prevalence of PGD after natural disasters was 38.81 % (95 % CI: 24.12-53.50, I2 = 99.7 %, p = 0 < 001).

Conclusions

It is recommended that policies and plannings of the organizations responsible for disaster management be prepared to send specialized teams of psycho-spiritual counseling, quickly accommodate the injured, and reconstruct the damaged buildings in the shortest time possible.

The change of working alliance and the association to treatment outcome in an internet-based therapy after pregnancy loss

BACKGROUND

Working alliance is a prominent non-specific factor for treatment outcomes in face-to-face and internet-based interventions. The association between working alliance and therapy outcome appears to be time- and disorder-specific, but less is known about the change of working alliance during the intervention and the impact of working alliance in grief-specific interventions. The present study examines the association between the change of working alliance and treatment outcomes in an internet-based intervention for parents who experienced pregnancy loss.

METHODS

228 participants received a grief intervention based on cognitive behavioral therapy with asynchronous text-based therapist feedback. Prolonged grief and related symptoms of traumatic stress, depression, anxiety, and general psychopathology were assessed with validated instruments before and after the intervention. The change of working alliance was assessed using the short version of the Working Alliance Inventory at mid-treatment (session 4) and the end of the treatment (session 10).

RESULTS

Data for N = 146 persons was analyzed. Working alliance in total and all subscales increased significantly from sessions 4 to 10. This change in working alliance correlated significantly with a reduction in prolonged grief. Changes in subscales of working alliance also correlated with symptoms of depression and general psychopathology. Regression analysis showed that a change in working alliance predicted a reduction in prolonged grief but did not predict improvements in other grief-related symptoms.

CONCLUSION

The results examine the change of working alliance during an internet-based intervention and the association with treatment outcome. A small impact of change in working alliance on treatment outcome of prolonged grief was confirmed, but not on related symptoms. Further research is needed to assess moderators of the alliance-outcome association to improve internet-based interventions.

TRIAL REGISTRATION

Not applicable.

Letter Writing as a Clinical Tool in Grief Psychotherapy

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.

Effects of an Integrated Treatment Program on Grief and Distress Among Parentally Bereaved Young Adults

This study examined the effectiveness of an 18-session manualized integrative group psychotherapy intervention for parentally bereaved young adults with grief complications. Participants, 63 young adults aged 20-27 years, completed questionnaires assessing symptoms of prolonged grief, PTSD, depression and anxiety prior to and following treatment. Treatment effectiveness was assessed by comparing outcomes for the intervention group to a waitlist comparison group. Results revealed a statistically significant reduction in symptoms of grief (large effects size), PTSD (medium effect sizes), and depression (medium effect size). The treatment did not result in a significant reduction in anxiety symptoms. The study provided preliminary support for this intervention for parentally bereaved young adults.

Complicated grief knowledge and practice: a qualitative study of general practitioners in Ireland

OBJECTIVE

Complicated grief is a debilitating condition that individuals may experience after losing a loved one. General practitioners (GPs) are well positioned to provide patients with support for grief-related issues. Traditionally, Irish GPs play an important role in providing patients with emotional support regarding bereavement. However, GPs have commonly reported not being aptly trained to respond to bereavement-related issues. This study explores GPs' current knowledge of and practice regarding complicated grief.

METHODS

A qualitative study adopting a phenomenological approach to explore the experiences of GPs on this issue. Semi-structured interviews were carried out with a purposive sample of nine GPs (five men and four women) in Ireland. Potential participants were contacted via email and phone. Interviews were audio-recorded, transcribed and analysed using Braun & Clarke's () model of thematic analysis.

RESULTS

GPs had limited awareness of the concept of complicated grief and were unfamiliar with relevant research. They also reported that their training was either non-existent or outdated. GPs formed their own knowledge of grief-related issues based on their intuition and experiences. For these reasons, there was not one agreed method of how to respond to grief-related issues reported by patients, though participants recognised the need for intervention, onward referral and review.

CONCLUSIONS

The research highlighted that GPs felt they required training in complicated grief so that they would be better able to identify and respond to complicated grief.

A cross-sectional examination of sudden-death bereavement in university students

ObjectivesThe objective of this research was to determine the unique contributions of sudden death bereavement to the mental health of university students compared to non-sudden death bereaved university students. Methods: We surveyed 1047 bereaved university students (retention rate 92%) and compared the non-sudden death bereaved university student population to the sudden death bereaved university population on outcomes including mental health symptomatology, and complicated grief using logistic regressions. Results: Sixty two percent of the sample reported sudden death bereavement. There were no differences on measures of PTSD, generalized anxiety disorder, depression, suicidal ideation, and at-risk drinking behavior across types of bereavement. However, sudden death bereavement compared to general bereavement was associated with increased likelihood of complicated grief. Conclusions: Sudden death bereavement in university students is associated with elevated risk of complicated grief. These findings confirm previous research and provide more insight into the unique needs of university student coping with sudden loss.

Experience of application of the meaning-centered psychotherapy to Japanese bereaved family of patients with cancer – A mixed-method study

Objectives

This study aimed to adapt the meaning-centered psychotherapy (MCP) to treat post-bereavement grief in Japanese bereaved families who lost their loved ones to cancer and to examine the feasibility of the intervention using both quantitative and qualitative methods.

Methods

A modified version of MCP was developed with cultural consideration. Bereaved individuals aged ≥18 years who had lost their family members to cancer at least 6 months before and had severe or persistent grief with a score of ≥26 on the Inventory of Complicated Grief (ICG-19) were included in the study. The participants received the modified version of MCP, which was provided in a 5-session monthly format. The levels of grief (ICG-19), depression (Center for Epidemiologic Studies Depression Scale [CES-D]), general health (General Health Questionnaire-12), and post-traumatic growth (Post-traumatic Growth Inventory -Short Form) were compared before and after the intervention.

Results

Five bereaved individuals were enrolled, and all the participants completed the program. The mean scores of the ICG-19. The participants’ sense of regret, guilt, and being separated from the deceased person gradually shifted to the reappraisal of the experience, leading to a broadened view of the relationship with the deceased, and rediscovery of the core values, identity, and roles of the participants through the process of rediscovery of the meaning of life.

Significance of results

A modified version of the MCP was well accepted by Japanese bereaved families. The intervention appears to promote the rediscovery of the meaning of life and appears to have the potential to alleviate the bereaved individuals’ depression and grief-related symptoms and to facilitate their post-traumatic growth.

The APSY-SED study: protocol of an observational, longitudinal, mixed methods and multicenter study exploring the psychological adjustment of relatives and healthcare providers of patients with cancer with continuous deep sedation until death

BACKGROUND

Since 2016, France is the only country in the World where continuous deep sedation until death (CDSUD) is regulated by law. CDSUD serves as a response to refractory suffering in palliative situations where the patients' death is expected to occur in the following hours or days. Little is known on the psychological adjustment surrounding a CDSUD procedure for healthcare providers (HCPs) and relatives. Our study aims to gather qualitative and quantitative data on the specific processes behind the psychological adjustment of both relatives and HCPs, after the administration of CDSUD for patients with cancer.

METHODS

The APSY-SED study is a prospective, longitudinal, mixed-methods and multicenter study. Recruitment will involve any French-speaking adult cancer patient for who a CDSUD is discussed, their relatives and HCPs. We plan to include 150 patients, 150 relatives, and 50 HCPs. The evaluation criteria of this research are: 1/ Primary criterion: Psychological adjustment of relatives and HCPs 6 and 13 months after the death of the patient with cancer (psychological adjustment = intensity of anxiety, depression and grief reactions, CDSUD-related distress, job satisfaction, Professional Stress and Professional experience). Secondary criteria: a)occurrence of wish for a CDSUD in patients in palliative phase; b)occurrence of wish for hastened death in patients in palliative phase; c)potential predictors of adjustment assessed after the discussion concerning CDSUD as an option and before the setting of the CDSUD; d) Thematic analysis and narrative account of meaning-making process concerning the grief experience.

DISCUSSION

The APSY-SED study will be the first to investigate the psychological adjustment of HCPs and relatives in the context of a CDSUD procedure implemented according to French law. Gathering data on the grief process for relatives can help understand bereavement after CDSUD, and participate in the elaboration of specific tailored interventions to support HCPs and relatives. Empirical findings on CDSUD among patients with cancer in France could be compared with existing data in other countries and with results related to other medical fields where CDSUD is also conducted.

TRIAL REGISTRATION

This protocol received the National Registration Number: ID-RCB2021-A03042-39 on 14/12/2021.

The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study's conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

'I will never love anyone like that again': cognitive behavioural therapy and the pathologisation and medicalisation of ordinary experiences

Psychiatry has a long history of being criticised for the pathologisation and medicalisation of ordinary experiences. One of the most prominent of these critiques is advanced by Allan Horwitz and Jerome Wakefield who argue that instances of ordinary sadness in response to events such as bereavement, heartbreak and misfortune, are being mistakenly diagnosed as depression due to an increasing lack of consideration for aetiology and contextual factors. Critiques concerning pathologisation and medicalisation have not been forthcoming for psychiatry's close cousin, psychotherapy. Using Cognitive Behavioural Therapy, one of the most prominent schools of contemporary psychotherapy as a case study, I demonstrate that psychotherapy also contributes to medicalising and pathologising bereavement, heartbreak and misfortune.

The Relationship Between Adult Attachment and Complicated Grief: A Systematic Review

Attachment insecurity, including attachment anxiety and attachment avoidance, is proposed as a key factor disrupting adaptive recovery following bereavement, resulting in complicated grief. However, findings are inconsistent across studies. This review aimed to synthesise existing research on attachment patterns in adults experiencing complicated grief to better understand this relationship. 22 cross-sectional and longitudinal studies (5149 participants), published between 2003 and 2020, met inclusion criteria. Higher levels of attachment anxiety were consistently associated with symptoms of complicated grief. Higher levels of attachment avoidance were associated with symptoms of complicated grief, although this relationship was less consistent. The review has implications for clinical practice as bereaved adults with insecure attachment histories may be particularly vulnerable to experiencing complicated grief. The research is limited by the reliance on mainly cross-sectional studies. Future research should focus on longitudinal studies, and studies that explore men's experiences, and of individuals living in non-Western countries.

Prognosticating COVID Therapeutic Responses: Ambiguous Loss and Disenfranchised Grief

Conventionally, therapeutic assessments, interventions, and treatments have focussed on death-related "losses and grief" responses. It is purported that the COVID-19 aftermath has resulted in losses that cannot always be encapsulated using this method. In search of reasoning, models and theories that explain the sweeping mass destruction that COVID-19 has caused, key concepts arise in terms of how we should deal with losses and in turn support patients in the health and social care sector, (notwithstanding formal therapeutic services). There is a crucial need to embrace ambiguous loss and disenfranchised grief into everyday terminology and be acquainted with these issues, thereby adapting how services/clinicians now embrace loss and grief work. Integral to this process is to recognize that there has been a disproportionate impact on Black and minority ethnic communities, and we now need to ensure services are "seriously culturally competent." Primary Care services/IAPT/health and social care/voluntary sector are all likely to be at the forefront of delivering these interventions and are already established gatekeepers. So, this article discusses the prognostic therapeutic response to non-death related losses and grief, not restricted to the formal echelons of therapeutic provision.

How can we know what we don't know? An exploration of professionals' engagement with complicated grief

OBJECTIVE

Research has shown that complicated grief has the potential to adversely affect bereaved individuals, and in this context, understanding how mental health professionals engage with it in practice is of relevance. Gaining an understanding of professionals' knowledge, attitudes, skills and training in relation to complicated grief could provide insights that will inform their training and professional development. The aim of this study was to consider professionals' engagement with complicated grief, as represented by self-reported knowledge, attitudes, skills and training.

METHODS

The study used a three-phase mixed methods design (systematic review, qualitative interviews, and a quantitative survey) with empirical data being collected from psychologists, psychiatrists and counselor/psychotherapists.

RESULTS

Analysis yielded 15 integrated findings across the three phases, which were grouped into two clusters: the first highlighted tension between professionals' reported confidence and competence and the second explored the parameters and contribution of research and training in this area.

CONCLUSION

Professionals' perception of their competence to work with complicated grief seems overstated and research and professional practice are not aligned.

PRACTICE IMPLICATIONS

These findings are positioned to inform empirically supported training that addresses identified deficits in professionals' knowledge, attitudes and skills. It is important therefore that training is reflective of the needs of different professional groups.

Problemy psychiczne po śmierci osoby bliskiej jako przedmiot ekspertyzy sądowej

Wśród różnych form przeżywania śmierci osoby bliskiej wymienia się żałobę, jej powikłaną postać a także współwystępujące z nią zaburzenia psychiczne (najczęściej zespoły lękowe, depresja, uzależnienie od substancji psychoaktywnych, zespół stresu pourazowego). Omówiono przypadek, w którym rodzice wystąpili do sądu o odszkodowanie i zadośćuczynienie za śmierć syna, który zginął na skutek obrażeń doznanych w wypadku drogowym. U powoda po śmierci syna wystąpiła reakcja żałoby, a u powódki stan żałoby powikłanej, z którym współwystępowały objawy depresyjne. Odmienne obrazy kliniczne u każdego z powodów były uwarunkowane innymi cechami osobowości, odmiennymi modelami radzenia sobie w sytuacjach trudnych, a także schorzeniami somatycznymi. Doprowadziło to do różnych implikacji orzeczniczych u każdego z badanych. W sprawach odszkodowawczych (śmierć osób bliskich) konieczna jest diagnostyka różnicowa pomiędzy żałobą, jej powikłaną formą a zaburzeniami o charakterze reaktywnym i endogennym. Przydatna jest w tym ocena psychologiczna predyspozycji osobowościowych a także mechanizmów radzenia sobie w sytuacjach obciążających. Niekorzystanie z leczenia psychiatrycznego lub terapii psychologicznej nie może przesądzać o braku zaburzeń psychicznych. W tego rodzaju sprawach opiniowanie wymaga szczególnej ostrożności i wyważonych ocen. Należy unikać nadmiernej medykalizacji przeżyć po stracie osoby bliskiej, ale nie można też traktować stanów psychopatologicznych jedynie w kategoriach fizjologicznej reakcji na śmierć bliskiego.

A Scoping Review of Interventions for Spousal Bereavement in Older Adults

The loss of a spouse is a common and natural life event for older adults. Nearly one of four older bereaved spouses experience prolonged grief, impaired function or chronic depression. Mechanisms underlying these and other long-term health risks are not well understood. We conducted a scoping literature review to examine the interventions and outcomes that have been studied for late-life spousal bereavement to date. We identified 22 studies of group and individual-level interventions with most studies concerning grief processes within the first year. Nearly all studies evaluated emotional and psychological symptoms of loss and a small number evaluated the restoration of adaptive functioning. Four interventions addressed the treatment of complicated grief or grief with major depressive disorder. Qualitative studies explored themes of spirituality and mindfulness. There were 17 controlled studies, including 13 randomized controlled trials. Findings were eclectic, with evidence supporting mindfulness techniques in a group format for emotional and life satisfaction outcomes; an individual, function-based therapy addressing sleep to improve emotion and function; an individual, writing-based emotional expression therapy for short-term improvement in emotion and function; nortriptyline for the treatment of bereavement-related major depressive disorder; a group-based, complicated grief therapy for this condition; an internet-based CBT intervention for prolonged grief; and pharmacotherapy for cardiovascular changes during bereavement. These findings highlight the small literature of methodologically strong intervention studies addressing spousal bereavement in older adults and the need for greater exploration of relevant biological, social, cognitive and behavioral factors to improve short and long term health outcomes.

Loss and bereavement in late life (60+): Study protocol for a randomized controlled trial regarding an internet-based self-help intervention

BACKGROUND

The death of a close person is a highly stressful, yet common life event in later life. While most individuals seem to cope well with bereavement, a substantial proportion of older individuals suffer from prolonged grief symptoms. E-mental health interventions have been shown to be efficient for a variety of psychological illnesses. Yet, there is a large research gap of studies with a special focus on older adults. This study protocol describes a randomized controlled trial for an internet-based self-help intervention addressing bereavement and loss in adults aged 60 years and over. The self-management intervention is based on techniques of cognitive behavioral therapy and consists of 8 modules. The objective of the AgE-health study is to evaluate the effectiveness and acceptability of this intervention in comparison to a bibliotherapy control group.

METHODS

The AgE-health study aims at implementing a randomized controlled trial. Eligible participants aged 60+ years will be randomly allocated to an intervention group (access to the intervention) or to an active control group (access to bibliotherapy). Primary outcome is the reduction in grief symptoms (13-item Prolonged Grief Inventory); secondary outcomes are depression, social activity and network, quality of life, self-efficacy, satisfaction with the intervention/bibliotherapy, loneliness, acceptability, up-take and adherence. Assessments will take place before the intervention (baseline) as well as 4 months (follow-up 1) after the intervention.

DISCUSSION

This study addresses an under-recognized and understudied mental health burden in later life and may add valuable insight into our knowledge about the effectiveness of eHealth interventions for loss and bereavement in late life. To our knowledge, the AgE-health study will be the first randomized controlled trial to evaluate the effectiveness of an internet-based intervention targeting prolonged grief in adults aged 60 years and over.

TRIAL REGISTRATION

The study has been registered at the German Clinical Trials Register (Identifier: DRKS00020595, Registered 30th July 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020595).

Mental Imagery in Patients with Prolonged Grief Disorder: a Comparison with Matched Bereaved Healthy Controls

Mental imagery is a transdiagnostic feature that has been increasingly researched in mental disorders in the past years. This study is the first to investigate mental imagery in individuals suffering from Prolonged Grief Disorder (PGD), a new disorder which will be included into the new edition of the International Classification of Diseases and Related Health Problems (ICD-11).Our objective was to find out to what extent patients suffering from PGD differ from healthy, but equally bereaved, controls in terms of mental imagery, and how mental imagery is related to psychopathology. Patients with PGD and matched bereaved healthy controls (n = 54) completed a mental imagery questionnaire specifically designed for the study, and other established measures of psychopathology. Patients suffering from PGD reported mental images more frequently, had less control over them, and described negative images as more vivid than did healthy controls. Also, in reaction to mental images, patients less frequently experienced joy, but more often grief, anger and guilt. Besides these group differences, significant correlations between mental imagery other psychopathological measures could be found. Mental imagery is clearly related to PGD. The underlying mechanisms on whether it is a developing or maintaining factor need to be addressed in future studies. Future research should also investigate in what way mental imagery might be used in therapeutic approaches.

Inclusion of the other in the self as a potential risk factor for prolonged grief disorder: A comparison of patients with matched bereaved healthy controls

Pathological grief has received increasing attention in recent years, as about 10% of the bereaved suffer from one kind of it. Pathological grief in the form of prolonged grief disorder (PGD) is a relatively new diagnostic category which will be included into the upcoming ICD-11. To date, various risk and protective factors, as well as treatment options for pathological grief, have been proposed. Nevertheless, empirical evidence in that area is still scarce. Our aim was to identify the association of interpersonal closeness with the deceased and bereavement outcome. Interpersonal closeness with the deceased in 54 participants (27 patients suffering from PGD and 27 bereaved healthy controls) was assessed as the overlap of pictured identities via the inclusion of the other in the self scale (IOS scale). In addition to that, data on PGD symptomatology, general mental distress and depression were collected. Patients suffering from PGD reported higher inclusion of the deceased in the self. By contrast, they reported feeling less close towards another living close person. Results of the IOS scale were associated with PGD severity, general mental distress and depression. Inclusion of the deceased in the self is a significant statistical predictor for PGD caseness.

The potential impact of bereavement grief on workers, work, careers, and the workplace

Bereavement grief is typically very painful and often highly consequential. People who are working could be significantly impacted by the death of someone they care about. A qualitative study sought an understanding of the lived experience of bereavement on the mourner's ability to work and their work-related experiences following the death of a loved one. Three themes emerged: (a) grief is universal but individually impactful, (b) accommodation is needed to assist the return to work and to regain work abilities, and (c) there are many impediments to working again. These themes highlight the potential for bereavement grief to substantially effect mourners and thus their work, careers, and the workplace. Older workers could be particularly disadvantaged because of workplace ageism. Societal and other changes appear to be needed for the health and wellbeing of mourning workers, and to address related work and bereavement issues. Bereavement grief is highly relevant to the social work profession, given its involvement in providing information, developing supportive services, and making referrals.

A "Third Wheel" Effect in Health Decision Making Involving Artificial Entities: A Psychological Perspective

In the near future, Artificial Intelligence (AI) is expected to participate more and more in decision making processes, in contexts ranging from healthcare to politics. For example, in the healthcare context, doctors will increasingly use AI and machine learning devices to improve precision in diagnosis and to identify therapy regimens. One hot topic regards the necessity for health professionals to adapt shared decision making with patients to include the contribution of AI into clinical practice, such as acting as mediators between the patient with his or her healthcare needs and the recommendations coming from artificial entities. In this scenario, a "third wheel" effect may intervene, potentially affecting the effectiveness of shared decision making in three different ways: first, clinical decisions could be delayed or paralyzed when AI recommendations are difficult to understand or to explain to patients; second, patients' symptomatology and medical diagnosis could be misinterpreted when adapting them to AI classifications; third, there may be confusion about the roles and responsibilities of the protagonists in the healthcare process (e.g., Who really has authority?). This contribution delineates such effects and tries to identify the impact of AI technology on the healthcare process, with a focus on future medical practice.

Clinical Hypnotherapy in Grief Resolution - A Case Report

Grief is one's reaction to any loss, and the coping mechanisms during grief either deplete or become maladaptive. One of the common ways to cope with grief is alcohol or substance intake. The course and resolution of grief vary depending upon many factors. Hypnotherapy has been useful and effective in addressing grief reactions as well as associated manifestation, such as sleep problems, depressive features, or post-traumatic stress disorder. It might be a good choice of treatment while dealing with patients having underlying issues or maladaptive coping mechanisms. This is a single case study design hypothesized to indicate maladaptive coping of increased alcohol consumption to deal with the death of a young son. The case had been treated as alcohol dependent syndrome with multiple hospitalizations without addressing underlying grief. The treatment approach was changed, and grief was addressed using hypnotherapy. Clinical hypnotherapy helped address grief and facilitated the index case to accept the loss. This resulted in minimizing hospitalizations, abstinence and improved day-to-day functioning along with the use of adaptive mechanisms to cope with the loss. Clinical hypnotherapy is an effective intervention to deal with underlying conflicts or issues that may not be addressed directly in a therapy setting.

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.

The importance of bereavement cognitions on grief symptoms: Applications of cognitive processing therapy

The experience of bereavement and trauma share some overlapping features, such as changes in the cognitive processing of information. This article explored the extent to which cognitive processes during bereavement influence coping outcomes in relation to grief in a sample of university students who had been previously bereaved (N = 104). First, we examined differences in bereavement outcomes based on whether cognitive processes associated with the bereavement were accommodated (n = 55), over-accommodated (n = 25), or assimilated (n = 24). Results indicate that grief-related outcomes significantly differed as a result of cognitive processes. We then compared the degree to which these cognitive processes accounted for grief outcomes in individuals with high and low grief symptoms. In individuals with low grief levels, both depressive symptoms and grief cognitions significantly accounted for grief levels. However, in individuals with high grief levels, only cognitive processes significantly accounted for levels of grief. Results from this study underscore the importance of examining cognitive processes during bereavement. Future research should further examine the underlying mechanisms that contextualize both the bereavement and cognitive processes surrounding the loss. Finally, results from this study highlight the associated cognitive processing of information as a potential topic for targeted treatment in bereavement.

[Prolonged grief disorder]

Grief is a natural response to the loss of a loved one and its intensity usually lessens over time. Approximately 10% of bereaved persons, however, experience persistent symptoms resulting in the development of a prolonged grief disorder (PGD). A PGD shows a distinct symptom cluster and is considered for inclusion as a diagnosis in the upcoming revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). It is distinct from other mental disorders but symptoms overlap, especially with major depression and posttraumatic stress disorder. In addition to diagnostic criteria and differential diagnosis, the following article also describes prevalence rates, comorbidities, risk factors as well as treatment options for PGD.

Treating prolonged grief disorder with prolonged grief-specific cognitive behavioral therapy: study protocol for a randomized controlled trial

BACKGROUND

Prolonged grief disorder (PGD) has emerged as a well-defined and relatively common mental disorder that will be included in the upcoming revision of the International Classification of Diseases. Recent trials with grief-specific, mostly cognitive behavioral interventions for patients with a clinically relevant diagnosis of PGD showed large effect sizes. However, a small trial suggested that non-specific behavioral activation might suffice to improve PGD. So, more evidence for the relative efficacy of grief-specific treatments is needed, as is more research on the predictors of treatment success. The purpose of the proposed trial is to evaluate a newly developed and successfully pilot-tested, prolonged grief-specific, integrative cognitive behavioral therapy (PG-CBT) compared to an active yet unspecific treatment, present-centered therapy (PCT).

METHODS

In a multicenter, randomized controlled trial with 204 adults with a primary diagnosis of PGD, PG-CBT is compared to PCT, assuming the superiority of PG-CBT. Both treatments consist of 20 to 24 individual sessions, with an overall treatment length of about 6 months. The primary outcome, grief symptom severity, is assessed by blinded interviewers 12 months after randomization. Secondary outcomes are grief symptom severity at post treatment, in addition to self-reported overall mental health symptoms, depressive and somatoform symptoms at post treatment and 12 months post randomization. Possible moderators and mediators of treatment success are also explored.

DISCUSSION

The trial is designed to avoid bias as much as possible (stratified randomization performed independently, blinded outcome assessment, intention-to-treat-analysis, balanced treatment dose, continuous supervision, control for allegiance effects) thereby enhancing internal validity. At the same time, some aspects of the trial will ensure clinical relevance (recruiting at outpatient clinics that are part of routine health care and keeping exclusion criteria to a minimum). Since the trial is powered adequately for the primary outcome, all secondary analyses including moderator analyses are exploratory by nature. The results will extend the knowledge on efficacious treatment of PGD and its predictors.

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012317 . Registered on 6 September 2017.

Does prolonged grief treatment foster posttraumatic growth? Secondary results from a treatment study with long-term follow-up and mediation analysis

OBJECTIVES

Prolonged grief disorder (PGD) is a persistent and disabling kind of grief reaction that can be treated effectively with psychotherapeutic interventions. There has been limited investigation of whether these interventions can also enhance positive outcomes of bereavement, such as posttraumatic growth or benefit finding.

DESIGN

As part of secondary analyses in a randomized controlled trial evaluating integrative cognitive-behavioural therapy for PGD (PG-CBT), the posttraumatic growth trajectories in 51 outpatients with clinically relevant prolonged grief symptoms were followed up from baseline up to 1.5 years.

METHODS

Immediate treatment effects on posttraumatic growth in comparison with a waiting list control group were evaluated with univariate ANCOVA. Using mediation analysis, we examined the relation between symptom reduction and the short-term treatment effect on posttraumatic growth. For evaluating long-term outcome stability, the immediately treated group and the delayed treatment group were pooled.

RESULTS

PG-CBT significantly fostered growth in patients suffering from PGD, with a controlled medium effect size of Cohen's d = 0.60 (completer analysis). This effect remained stable up to the 1.5-year follow-up. Grief symptom reduction mediated short-term treatment effects on posttraumatic growth. However, growth also partially mediated treatment effects on prolonged grief symptoms.

CONCLUSIONS

Taken together, PG-CBT was effective in enhancing the participants' perception of posttraumatic growth, but the definite interaction between symptom reduction and posttraumatic growth remains unclear, as both seemed to influence each other's trajectory in the course of treatment.

PRACTITIONER POINTS

Integrative CBT for prolonged grief disorder also fostered posttraumatic growth. Post-treatment and 1.5-year follow-up effect sizes for posttraumatic growth were moderate. Whether growth-enhancing techniques are useful in grief treatment needs further research.

Effectiveness of bereavement counselling through a community-based organization: A naturalistic, controlled trial

This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling model for adults on reducing complicated grief (CG) symptoms. Participants (N = 344; 79% female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was hypothesized that participants who received intervention would experience a greater decline in CG levels immediately following the intervention compared to the control participants, but the difference would diminish at follow‐up (due to relapse). Data were collected via postal questionnaire at 3 time points: baseline (T), post‐intervention (T + 12 months), and follow‐up (T + 18 months). CG, post‐traumatic stress, and general psychological distress were assessed at all time points. Multilevel analyses controlling for relevant covariates were conducted to examine group differences in symptom levels over time. A stepwise, serial gatekeeping procedure was used to correct for multiple hypothesis testing. A main finding was that, contrary to expectations, counselling intervention and control group participants experienced a similar reduction in CG symptoms at postmeasure. However, intervention participants demonstrated a greater reduction in symptom levels at follow‐up (M = 53.64; d = .33) compared to the control group (M = 62.00). Results suggest community‐based bereavement counselling may have long‐term beneficial effects. Further longitudinal treatment effect investigations with extensive study intervals are needed.

Therapeutic Assessment With a Client With Persistent Complex Bereavement Disorder: A Single-Case Time-Series Design

This article presents the results of a study into the effectiveness of therapeutic assessment (TA), a brief form of intervention that incorporates the results of assessment findings into psychological treatment. The history of Anthony, a man who reported symptoms of persistent complex bereavement disorder (PCBD), associated with major depression disorder (MDD) and post-traumatic stress disorder (PTSD), is presented. After his parents’ deaths, Anthony became detached from reality, lost all pleasure in his everyday life, and found it impossible to overcome the devastating feelings related to the loss. Following TA principles, the assessor created a supportive and empathic relationship with Anthony and helped him attain his goals for the assessment. The assessment was monitored using a single-case quasi-experimental design with time-series analysis. Results of this study revealed a specific trajectory of Anthony’s self-reported symptoms and a statistically significant trend toward improvement in severity at the end of the TA. This case study highlights the utility and efficacy of TA in helping clients process traumatic losses and complicated bereavements.

Participant experiences of Eye Movement Desensitisation and Reprocessing vs. Cognitive Behavioural Therapy for grief: similarities and differences

Background and Objective: Previous research has used quantitative methods to assess the impact of grief therapy. However, rarely have participants been asked about how they have been affected by treatment using qualitative methods. This study sought to explore participants' experiences of two therapeutic approaches to grief: Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). Method: Nineteen participants were randomly allocated to receive seven weekly therapy sessions of either CBT or EMDR. Approximately two weeks after completing therapy, a semi-structured interview was conducted with each participant. Interviews were transcribed and a thematic analysis was performed. Results: Participant reports common to both therapies included developments in insight, a positive shift in emotions, increased activity, improved self-confidence and a healthier mental relationship to the deceased. Participants also responded by describing experiences that were unique to each therapy. Those who completed CBT described the acquisition of emotion regulation tools and shifting from being in an ongoing state of grief to feeling that they were at a new stage in their lives. Participants who completed EMDR reported that distressing memories were less clear and felt more distant from such memories following treatment. Conclusions: Although both therapies resulted in some similar changes for participants, there were unique experiences associated with each therapy. These findings are discussed in terms of implications for the underlying key processes of each therapy and the processes of recovery in grief.

Prolonged grief, depression, and posttraumatic stress in disaster-bereaved individuals: latent class analysis

Background: Hundreds of individuals lost one or more significant others in the MH17 plane crash in 2014 in Ukraine. The current study is the first to explore subgroups of disaster-bereaved individuals based on presence of psychopathology clusters. This may inform the development of diagnostic instruments and tailored interventions. Objective: Aims of the current study were to examine (1) subgroups based on presence of prolonged grief disorder (PGD), major depressive disorder (MDD), and posttraumatic stress disorder (PTSD) symptom clusters and (2) associations between class membership, disaster-related variables (i.e. experiencing multiple losses, conducting multiple burials for the same deceased, and time to confirmation of death), and a sense of unrealness. Method: Self-rated PGD (10 items of the Traumatic Grief Inventory represented in two symptom clusters), MDD (16-item Quick Inventory Of Depressive Symptomatology represented in one symptom cluster), and PTSD (20-item PTSD Checklist for DSM-5 represented in four symptom clusters) from 167 participants were subjected to latent class analysis to identify subgroups (i.e. classes). Correlates of class membership were assessed using the three-step approach. Results: A three-class solution yielded the best model fit. Class 1 (Resilient class; 20.0%) was predominantly characterized by low probability of PGD, MDD, and PTSD symptom clusters, class 2 (PGD class; 41.8%) by moderate to high probability of presence of PGD, and class 3 (Combined class; 38.2%) by moderate to high probability of presence of PGD, MDD, and PTSD symptom clusters. Compared with the Resilient class, a sense of unrealness was more likely to be experienced by individuals in the PGD class and the Combined class. Conclusions: Our results indicate that subgroups of disaster-bereaved individuals can be distinguished based on the presence of PGD, MDD, and PTSD symptom clusters. A sense of unrealness was the strongest distinguishing feature of the subgroups.

On Mourning and Recovery: Integrating Stages of Grief and Change Toward a Neuroscience-Based Model of Attachment Adaptation in Addiction Treatment

Interpersonal attachment and drug addiction share many attributes across their behavioral and neurobiological domains. Understanding the overlapping brain circuitry of attachment formation and addiction illuminates a deeper understanding of the pathogenesis of trauma-related mental illnesses and comorbid substance use disorders, and the extent to which ending an addiction is complicated by being a sort of mourning process. Attention to the process of addiction recovery-as a form of grieving-in which Kubler-Ross's stages of grief and Prochaska's stages of change are ultimately describing complementary viewpoints on a general process of neural network and attachment remodeling, could lead to more effective and integrative psychotherapy and medication strategies.

Evaluating the Efficacy of EMDR With Grieving Individuals: A Randomized Control Trial

This study compared the effectiveness of eye movement desensitization and reprocessing (EMDR) with an integrated cognitive behavioral therapy (CBT) intervention for grief. Nineteen participants (12 females and 7 males) who identified themselves as struggling with grief were randomly allocated to treatment conditions. Each participant was wait-listed for 7 weeks and then received 7 weeks of therapy. There were no significant improvements on any measure in the wait-list period. In contrast, participants in both treatment groups improved on measures of grief (ηp2 = .47), trauma symptoms (ηp2 = .60), and distress (ηp2 = .34). There was no significant improvement in participants’ scores on a quality of life measure (ηp2 = .11). Neither treatment approach produced better outcomes than the other. For those who scored in the clinical range at intake, 72% achieved clinical and reliable change on the grief measure and 82% on the trauma measure. The study had several strengths, including randomization to treatment condition, multiple therapists, formal assessment of treatment fidelity, and the pretreatment and follow-up assessments were conducted by researchers blind to treatment assignment. Overall, the findings indicate that EMDR and CBT are efficacious in assisting those struggling with grief, and that those individuals reporting higher levels of distress and lower levels of functioning may benefit the most from an intervention.

Lessons from the 2004 Asian tsunami: Nature, prevalence and determinants of prolonged grief disorder among tsunami survivors in South Indian coastal villages

BACKGROUND

Prolonged grief disorder (PGD), previously called complicated grief, is associated with significant distress and long-term disability, and it may complicate assessments for post-traumatic stress disorder (PTSD) after traumatic events.

METHODS

In order to distinguish PGD from PTSD, we conducted a cross-sectional survey among tsunami survivors in five tsunami-affected coastal villages in India, 9 months after the Asian tsunami.

RESULTS

Prevalence of PGD among 643 tsunami survivors was 14.2% (95% confidence interval (CI): 11.5%-16.9%) and among the 351 bereaved survivors was 25.9% (95% CI: 21.3%-30.5%). Spousal bereavement, extensive damage to homes, fewer years of education, and absence of tsunami-related physical injury differentiated those with PGD, after adjusting for potential confounders (p < .05). These factors were distinct from the factors associated with post-traumatic stress symptoms (PTSS) among these survivors. Scores on the avoidance, hyper-arousal and intrusion subscales of the Impact of Events Scale-Revised were significantly lower in those with PGD alone than in those with PTSS or with both disorders.

CONCLUSION

Our findings support the validity of PGD in a non-Western post-disaster community and its distinctness from PTSD. They have important public health implications in planning responses to natural disasters and for future revisions of diagnostic classifications.

Efficacy of an integrative CBT for prolonged grief disorder: A long-term follow-up

BACKGROUND

While some intervention trials have demonstrated efficacy in treating prolonged grief disorder (PGD), data on long-term treatment effects are scarce.

METHODS

Fifty-one outpatients with clinically relevant prolonged grief symptoms, who had participated in a randomized controlled trial (RCT), were followed up, on average, 1.5 years after integrative cognitive behavioral therapy for PGD (PG-CBT). Initial assessment procedures were repeated, with PGD symptom severity as the main outcome and general mental health symptoms as secondary outcomes. As results in the immediate and delayed treatment groups (former wait list) were similar, the follow-up data were pooled.

RESULTS

Overall, 80% of the original ITT sample could be reached, that is 89% of the 37 treated participants, as well as 8 out of 14 participants who had dropped out of the RCT. The considerable short-term treatment success of PG-CBT was stable; pre to follow-up Cohen׳s d was large, with 1.24 in the ITT analysis and 2.22 for completers. The pre to post-improvement in overall mental health was maintained.

LIMITATIONS

Since the RCT wait list group had been treated after their waiting period as well, no controlled long-term outcomes are available.

CONCLUSIONS

PG-CBT proved to be effective in the longer run. In comparison to other RCTs on prolonged grief this is the largest sample followed up for this long.

Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial

BACKGROUND

Abnormal forms of grief, currently referred to as complicated grief or prolonged grief disorder, have been discussed extensively in recent years. While the diagnostic criteria are still debated, there is no doubt that prolonged grief is disabling and may require treatment. To date, few interventions have demonstrated efficacy.

METHODS

We investigated whether outpatients suffering from prolonged grief disorder (PGD) benefit from a newly developed integrative cognitive behavioural therapy for prolonged grief (PG-CBT). A total of 51 patients were randomized into two groups, stratified by the type of death and their relationship to the deceased; 24 patients composed the treatment group and 27 patients composed the wait list control group (WG). Treatment consisted of 20-25 sessions. Main outcome was change in grief severity; secondary outcomes were reductions in general psychological distress and in comorbidity.

RESULTS

Patients on average had 2.5 comorbid diagnoses in addition to PGD. Between group effect sizes were large for the improvement of grief symptoms in treatment completers (Cohen׳s d=1.61) and in the intent-to-treat analysis (d=1.32). Comorbid depressive symptoms also improved in PG-CBT compared to WG. The completion rate was 79% in PG-CBT and 89% in WG.

LIMITATIONS

The major limitations of this study were a small sample size and that PG-CBT took longer than the waiting time.

CONCLUSIONS

PG-CBT was found to be effective with an acceptable dropout rate. Given the number of bereaved people who suffer from PGD, the results are of high clinical relevance.

Prolonged grief: setting the research agenda

BACKGROUND

Prolonged grief disorder is proposed for the International Classification of Diseases (ICD-11), though it was rejected as a diagnosis for DSM-5.

OBJECTIVE

This review outlines findings and defines important areas for future research viewed from a lifespan perspective.

RESULTS

The development and psychometric evaluation of measures for the new diagnosis is paramount, specifically for children and adolescents. Treatments need to be adapted for specific subgroups and research findings have to be disseminated into various professional settings.

Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG): toward integrated treatment of symptoms related to traumatic loss

BACKGROUND

Traumatic events such as disasters, accidents, war, or criminal violence are often accompanied by the loss of loved ones, and may then give rise to traumatic grief. Traumatic grief refers to a clinical diagnosis of persistent complex bereavement disorder (PCBD) with comorbid (symptoms of) posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD) following confrontation with a traumatic loss. Trauma survivors, who are frequently from different cultural backgrounds, have often experienced multiple losses and ambiguous loss (missing family members or friends). Current evidence-based treatments for PTSD do not focus on traumatic grief.

OBJECTIVE

To develop a treatment for traumatic grief combining treatment interventions for PTSD and PCBD that may accommodate cultural aspects of grief.

METHOD

To provide a rationale for treatment, we propose a cognitive stress model of traumatic grief. Based on this model and on existing evidence-based treatments for PTSD and complicated grief, we developed Brief Eclectic Psychotherapy for Traumatic Grief (BEP-TG) for the treatment of patients with traumatic grief. The treatment is presented along with a case vignette.

RESULTS

Processes contributing to traumatic grief include inadequately integrating the memory of the traumatic loss, negative appraisal of the traumatic loss, sensitivity to matching triggers and new stressors, and attempting to avoid distress. BEP-TG targets these processes. The BEP-TG protocol consists of five parts with proven effectiveness in the treatment of PCBD, PTSD, and MDD: information and motivation, grief-focused exposure, memorabilia and writing assignments, finding meaning and activation, and a farewell ritual.

CONCLUSION

Tailored to fit the needs of trauma survivors, BEP-TG can be used to address traumatic grief symptoms related to multiple losses and ambiguous loss, as well as cultural aspects of bereavement through its different components.

Lessons from writing sessions: a school-based randomized trial with adolescent orphans in Rwanda

BACKGROUND

Treatments for adolescents affected by long-term loss in low- and middle-income countries are lacking. As school-based interventions are cost-efficient and easy to disseminate, an evaluation of this treatment setting for adolescents is worthwhile.

OBJECTIVE

Examining the effect of a school-based unstructured emotional writing intervention (sensu Pennebaker, group 1) about the loss of a parent to reduce adaptation problems to loss, compared to writing about a hobby (group 2), and non-writing (group 3).

METHOD

We randomly assigned 14-18-year-old Rwandan orphans to one of the three conditions (n=23 per condition). Before and after the intervention, subjects completed the Prolonged Grief Questionnaire for Adolescents and the Mini International Neuropsychiatric Interview for Children and Adolescents, Part A, on depression as self-report measures of long-term effects of early parental loss.

RESULTS

Repeated measures analyses of variance showed no differential effect for any of the three conditions but revealed a significant effect of time at posttest regarding grief severity. Reduction of grief symptoms was significantly higher in subjects with elevated grief. Depressive symptoms showed no significant change from pre- to posttest in the emotional writing condition, whereas they significantly decreased in the control condition.

CONCLUSIONS

RESULTS imply that unstructured, brief emotional writing might not be indicated in adolescents affected by early parental loss who show severe and long-term distress; a more structured approach seems recommendable.

Losing a child: finding meaning in bereavement

BACKGROUND

Confronting the loss of a loved one leads us to the core questions of human existence. Bereaved parents have to deal with the rupture of a widely shared concept of what is perceived to be the natural course of life and are forced into meaning reconstruction.

OBJECTIVE

This study aims to expand upon existing work concerning specific themes of meaning reconstruction in a sample of bereaved parents. More specifically, the relationship between meaning reconstruction, complicated grief, and posttraumatic growth was analyzed, with special attention focused on traumatic and unexpected losses.

METHOD

In a mixed methods approach, themes of meaning reconstruction (sense-making and benefit-finding) were assessed in in-depth interviews with a total of 30 bereaved parents. Posttraumatic growth and complicated grief were assessed using standardized questionnaires, and qualitative and quantitative results were then merged using data transformation methods.

RESULTS

In total 42 themes of meaning reconstruction were abstracted from oral material. It was shown that sense-making themes ranged from causal explanations to complex philosophical beliefs about life and death. Benefit-finding themes contained thoughts about personal improvement as well as descriptions about social actions. Significant correlations were found between the extent of sense-making and posttraumatic growth scores (r s=0.54, r s=0.49; p<0.01), especially when the death was traumatic or unexpected (r s=0.67, r s=0.63; p<0.01). However, analysis revealed no significant correlation with complicated grief. Overall results corroborate meaning reconstruction themes and the importance of meaning reconstruction for posttraumatic growth.

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.

Treatment of complicated grief

Following the death of a loved one, a small group of grievers develop an abnormal grieving style, termed complicated or prolonged grief. In the effort to establish complicated grief as a disorder in DSM and ICD, several attempts have been made over the past two decades to establish symptom criteria for this form of grieving. Complicated grief is different from depression and PTSD yet often comorbid with other psychological disorders. Meta-analyses of grief interventions show small to medium effect sizes, with only few studies yielding large effect sizes. In this article, an integrative cognitive behavioral treatment manual for complicated grief disorder (CG-CBT) of 25 individual sessions is described. Three treatment phases, each entailing several treatment strategies, allow patients to stabilize, explore, and confront the most painful aspects of the loss, and finally to integrate and transform their grief. Core aspects are cognitive restructuring and confrontation. Special attention is given to practical exercises. This article includes the case report of a woman whose daughter committed suicide.