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.

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.

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.