Recent Trends in the Treatment of Prolonged Grief

Anthony D. Mancini; Paul Griffin; George A. Bonanno

Disclosures

Curr Opin Psychiatry. 2012;25(1):46-51. 

In This Article

Grief Treatments

The primary mode of intervention for grief has been individual and group psychotherapy, but other approaches have recently been tested, including internet-based interventions, preventive interventions, and pharmacotherapy.

Individual Psychotherapy

CBT and other related approaches have received the most rigorous empirical attention and validation. One recent CBT model theorizes that poor integration of the loss into autobiographical memory, negative interpretations of one's symptoms, and anxious and depressive avoidance strategies are the three main contributors to complicated grief.[31] On the basis of this model, and consistently with treatments for posttraumatic stress disorder, CBT grief interventions usually employ some form of cognitive restructuring and exposure. Cognitive restructuring techniques help the griever to identify problematic aspects of the loss and to revise their understanding of them. Exposure techniques typically involve imaginal, such as telling the story of the loss, and in-vivo components, such as confronting avoidance of places or people associated with the loss.

In two recent high-quality randomized controlled trials, a CBT intervention provided substantial benefits to grievers. A key component of each of these studies is that rigorous screening procedures were used to identify grievers with high levels of distress. One study dismantled the components of CBT treatment (cognitive restructuring and exposure therapy), and compared them individually and in combination with supportive counseling.[32] Both CBT components proved more effective than supportive counseling, but exposure treatment achieved the best results. In another randomized controlled trial,[33] a CBT-based grief treatment based on the model by Shear[34] of complicated grief was compared with interpersonal therapy.[35] The intervention targeted the experience of loss (using exposure and restructuring techniques) and restorative processes (goal setting and improved relationships). Results showed that 51% of grievers who received complicated grief treatment responded, whereas 28% of grievers responded to interpersonal therapy.[33] These results argue for the efficacy of CBT approaches that target distressed grievers. However, it is important to note that meta-analytic findings have yet to show that CBT is superior to other therapy types.

Group Psychotherapy

Group modalities have long been used in grief therapy. Some recent studies have found positive results. In one study, inpatients with complicated and comorbid disorders were randomized to a manualized group therapy treatment that combined exposure therapy, psycho-education, and structured exercises or to a treatment as usual condition.[36] The intervention group saw significantly reduced grief symptoms when compared with treatment as usual, with a reported effect size of 1.21. In further support of the potential role of group therapy, Piper et al.[37] investigated the effects of short-term group therapy for prolonged grief. Their research provided some support for the effectiveness of interpretive therapy, an approach designed to help the client develop tolerance for the ambivalent feeling that complicated grievers feel toward the person they have lost.[37,38] Significant treatment effects were related to either group composition, such as the number of individuals high in mature interpersonal relationships,[38] or intrapersonal variables, such as attachment insecurity predicting more negative results.[39]

Family-based Psychotherapy

There are relatively few studies of family-based grief interventions. One randomized controlled study of family-based CBT for relatives of suicide victims found that 13 months postdeath treated individuals failed to report fewer grief symptoms.[40] A later analysis found that CBT treatment worked best for individuals showing higher levels of suicidal ideation,[41] again suggesting that grief interventions are most effective for persons with higher levels of distress.

Internet-based Approaches

Some recent approaches have used the internet as a way of providing treatment. A CBT treatment using web and e-mail exercises related to exposure, cognitive restructuring, and integration found that individuals with complicated grief responded better than those assigned to a waiting control group, with a significantly larger reduction in grief and anxiety symptoms that was maintained almost a year and a half later.[42–44] Does writing about the possible positive outcomes or meaning of a loss have beneficial effects? A randomized controlled internet study examined the effects of written disclosure on prolonged grief.[45] Within a nonclinical sample, reductions in grief symptoms were largest in a group instructed to examine possible benefits of their loss, although the difference from a neutral control group was statistically nonsignificant. Another internet study sought to examine the efficacy of online exercises intended to educate and support uncomplicated grievers.[46] A randomized controlled trial found that recently bereaved individuals who were exposed to a series of psycho-educational videos normalizing the grief experience self-reported significant improvements in attitude and self-efficacy regarding grief, as well as reductions in anxiety.

Preventive Interventions

Can the impact of a loss be ameliorated with preventive interventions? In their meta-analysis, Wittouck et al.[20] analyzed preventive interventions to assess their efficacy. In contrast to grief interventions for high-distress grievers, prevention treatments designed to reduce the probability of the occurrence of complicated grief showed nonsignificance at posttreatment and follow-up. However, one recent high-quality study of a multisite prevention program showed favorable results.[47] Bereaved caregivers of persons with Alzheimer's disease were randomized to a preventive intervention or treatment as usual. The authors found a significant, though modest (d = 0.28), reduction in general grief symptoms for the intervention group.[47]

Pharmacotherapy

There is growing interest in the application of pharmacotherapy to grief. Recent findings suggest that antidepressant medication may play a useful role in treating grief-related distress. The naturalistic use of pharmacotherapy in a randomized controlled trial of a grief psychotherapy intervention indicated that patients who used antidepressant medication were more likely to complete treatment, but only when randomized to the grief intervention and not a comparison treatment of interpersonal psychotherapy.[48] This study suggests that antidepressant medication may help patients tolerate grief psychotherapy, which often requires that patients confront painful experiences. Another recent uncontrolled study of escitalopram found that it had significant effects on bereavement-related depression,[49] a result consistent with previous uncontrolled studies of paroxetine.[50] Neither study used randomization, however, limiting their ability to determine the unique contributions of psychotherapy and pharmacotherapy.

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