Research reportEfficacy of an integrative CBT for prolonged grief disorder: A long-term follow-up
Introduction
Over the last two decades, prolonged or complicated grief has emerged as a well-defined mental disorder, distinguishable from major depression and posttraumatic stress disorder or other stress-related or anxiety disorders (for overviews see Bryant, 2014, Jordan and Litz, 2014). Core symptoms are intense yearning and preoccupation with the deceased; reactive distress symptoms, such as feeling stunned or shocked by the loss; avoidance of reminders of the reality of the loss and emotional numbing, and finally social/identity disruption, for instance feeling detached or having difficulties trusting others (Prigerson et al., 2009). Such symptoms should cause clinically significant impairment and persist longer than what would be deemed normative regarding an individual׳s cultural background (Maercker et al., 2013). In ICD-11, where the diagnosis will be included as “prolonged grief disorder” (PGD), the duration criterion will probably be six months after the death of a significant other (Jordan and Litz, 2014). Prevalence rates of prolonged grief were found to be 3.7% in a German sample (Kersting et al., 2011) and 4.8% in a Dutch sample of older adults (Newson et al., 2011). In the case of bereavement, prevalences ranged from 6.7% (Kersting et al., 2011) up to 25.4% in older adults (Newson et al., 2011). PGD has been found to be associated with deteriorated health (Stroebe et al., 2007), increased depression, and suicidality (Boelen and Prigerson, 2007, Latham and Prigerson, 2004).
Meta-analyses on grief interventions indicate that the distinction between normal, non-pathological grief and clinically impairing prolonged grief is important. Whereas non-selective interventions for the bereaved were found to be ineffective at best, psychotherapy for clinically relevant prolonged grief symptoms was found to be at least of moderate effectiveness (Currier et al., 2008; cf. Rosner and Hagl, 2007). The most recent meta-analysis found a non-significant effect size (ES) of 0.03 for preventive studies and a significant, albeit heterogeneous ES of 0.53 for the treatment of clinically relevant prolonged grief (Wittouck et al., 2011). Treatment studies are still rare (in Wittouck et al., 2011), analysis was based on five studies, two of them group interventions). However, there is growing evidence from randomized controlled trials (RCTs) that indicated and specific grief interventions are effective for PGD in different settings, that is, both in individual treatment (e.g., Boelen et al., 2007, Shear et al., 2005) and in group therapy (Supiano and Luptak, 2014), or when delivered via the Internet (Wagner et al., 2006). In newer studies with more recently bereaved individuals, Internet-based grief interventions even showed effectiveness with high risk populations that were not selected for PGD at all (Kersting et al., 2013), or, in terms of indicated prevention, with individuals manifesting grief symptoms on substantial but subthreshold levels (Litz et al., 2014). And recently, a small trial suggested that non-specific behavioral activation (together with functional assessment and education regarding grief symptoms) might suffice to profoundly improve PGD (Papa et al., 2013). Overall, these newer RCTs attest to the efficacy of structured, behavioral interventions for PGD, with moderate to high ES when compared to wait list.
However, studies with long-term follow-ups are rare. In the study by Boelen et al. (2007), a combination of exposure followed by cognitive restructuring resulted in significant improvements in prolonged grief with high pre- to post-treatment ES. These improvements could be maintained up to the 6-month follow-up: Pre- to follow-up assessment Cohen׳s d was 1.82 for completers (n=16) and 1.25 in intention-to-treat (ITT) analysis (n=23). A vice versa combination with cognitive restructuring followed by exposure still achieved ES of 1.41 for completers (n=16) and 0.83 for the ITT sample (n=20). In terms of general psychopathology, the long-term ES in the more successful therapeutic combination were 1.55 for completers and 1.20 for the ITT sample. Wagner and Maercker (2007) conducted a 1.5 year follow-up for their Internet-based grief intervention (Wagner et al., 2006) and reported that all treatment gains could be maintained (completer analysis only; n=22). Finally, Papa et al. (2013) found that the considerable treatment gains in their study could be maintained up to three months (n=20).
In order to develop our intervention for PGD we had reviewed earlier successful trials, together with the results of meta-analyses, to identify the most promising treatment strategies (Rosner and Hagl, 2007). Those were (1) education about normal and prolonged grief processes, (2) exposure to the most painful aspects of the loss, together with cognitive restructuring, and (3) transformation of the loss to enable change. Elements from Gestalt therapy, systemic family therapy and psychodrama were included; so this therapy should be viewed as an integrative cognitive behavioral therapy targeting maladaptive prolonged grief (PG-CBT; Rosner et al., 2011).
PG-CBT was then evaluated in a first RCT, with 51 participants suffering from clinically relevant PGD symptoms (Rosner et al., 2014). Immediate treatment effects were considerable, with within-group effect sizes for the 19 PG-CBT completers of d=1.65 for grief severity (d=1.26, for the ITT sample), and d=0.68 for general mental health symptoms (d=0.64 for ITT). For grief severity, PG-CBT showed a significantly better outcome than the untreated wait list control, with large between-group effect sizes (d=1.61 for completers; d=1.32 in the ITT analysis). For overall general mental health symptoms, PG-CBT did not achieve better outcomes than wait list; however, a look at subscales revealed significantly more improvement in depressive symptoms (d=0.60 for completers; d=0.73 in the ITT analysis). Overall, PG-CBT was shown to be effective and specific for PGD treatment. Below, we report the results of the subsequently treated wait list group of the original RCT, together with long-term follow-up data, pooled for all treated patients. Our research examined whether the initial symptom improvement could be maintained in the long-term.
Section snippets
Procedure
The study was approved by the University׳s Ethics Committee and has been registered with Clinical Trials (Identifier: NCT01433653). Participants gave written informed consent concerning study procedures and being contacted for follow-up. The original RCT was conducted between October 2006 and February 2011, with a wait list as control group. The randomized sample had been stratified according to the patient׳s relationship to the deceased, i.e., a child or other form of kinship, and according to
Results for the delayed treatment group
Nine (33%) of the 27 participants who had originally been allocated to the wait list, dropped out: four of them during waiting, and five during treatment, after 8–13 sessions (see Fig. 1). Therapy completion amounted to 78%, while overall study compliance at post-test was 67% in this group. On average, treatment completers attended 23.50 sessions (SD=2.64; range: 16–25), and therapies lasted from 6 to 15 months, on average 10.25 months (SD=2.59).
Concerning primary and secondary outcomes,
Discussion
PG-CBT had been shown to be effective in the treatment of PGD in relation to a wait list control group (Rosner et al., 2014). Findings of this follow-up show that these initial therapy gains could be maintained, on average 1.5 years after post-assessment: ES from pre to follow-up were large, with d=1.24 for ITT analysis and d=2.22 in completers, similar to the results of Boelen et al. (2007) at 6-month follow-up. In the case of ITT analysis, the significant post to follow-up improvement in
Role of funding source
The actual therapy hours were compensated through the health insurance system. The study itself has not been funded.
Conflict of interest
R. Rosner, G. Pfoh, M. Kotoučová, and M. Hagl are co-editors of a book on grief treatment published at Hogrefe. This book contains a chapter with the manual for PG-CBT written by G. Pfoh, R. Rosner, and M. Kotoučová.
Acknowledgment
We thank Nicole Pertl who gathered and entered parts of the data. And we thank the participants of this study, who were ready to share their experiences once again for this follow-up.
References (29)
- et al.
Prevalence and determinants of complicated grief in general population
J. Affect. Disord.
(2010) - et al.
Prevalence of complicated grief in a representative population-based sample
J. Affect. Disord.
(2011) - et al.
A randomized controlled trial of an internet-based therapist-assisted indicated preventive intervention for prolonged grief disorder
Behav. Res. Ther.
(2014) - et al.
The prevalence and characteristics of complicated grief in older adults
J. Affect. Disord.
(2011) - et al.
A randomized open trial assessing the feasibility of behavioral activation for pathological grief responding
Behav. Ther.
(2013) - et al.
Efficacy of an outpatient treatment for prolonged grief disorder: a randomized controlled clinical trial
J. Affect. Disord.
(2014) - et al.
Health outcomes of bereavement
Lancet
(2007) - et al.
The prevention and treatment of complicated grief: a meta-analysis
Clin. Psychol. Rev.
(2011) - et al.
Treatment of complicated grief: a comparison between cognitive-behavioral therapy and supportive counselling
J. Consult. Clin. Psychol.
(2007) - et al.
The influence of prolonged grief disorder, depression and anxiety on quality of life among bereaved adults. A prospective study
Eur. Arch. Psychiatry Clin. Neurosci.
(2007)
Prolonged grief: where to after diagnostic and statistical manual of mental disorders
Curr. Opin. Psychiatry
The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review
Psychol. Bull.
SCL-90-R: Administration, Scoring and Procedures Manual for the R(evised) Version
Cited by (57)
Latent classes of prolonged grief and other indicators of mental health in bereaved adults: A systematic review
2023, Journal of Affective Disorders ReportsGroup-based compassion-focused therapy for prolonged grief symptoms in adults – Results from a randomized controlled trial
2022, Psychiatry ResearchCitation Excerpt :Using a pre-post repeated-measures design, a sample size of 2 × 38 would enable the detection of a difference of Cohen's d: 0.65 between CFT compared with the waitlist control group with a two-sided alpha of 0.05, a pre-post correlation (Rho) of 0.5, and a statistical power of 0.90. While this ES is larger than the pooled ESs found in previous meta-analyses, this was chosen as previous studies have generally found large effects of psychological interventions for PGS which includes cognitive techniques, with Cohen's d ranging from 0.80 to 1.36 compared with wait-list controls (Boelen et al., 2007; Rosner et al., 2015; Supiano and Luptak, 2014). On this background, an intervention with a small ES would be questionable in terms of clinical utility.
Grief and loss in old age: Exploration of the association between grief and depression.
2021, Journal of Affective DisordersCitation Excerpt :All items use a five-point rating scale in varying answer options, with higher values indicating higher symptom strength or frequency. In the present study we used a continuous cumulative score of the questions on stress symptoms as severity of grief burden-score, as in Rosner et al. (2014; 2015). The standardized interviews also included the De Jong Gierveld Short Scale for emotional and social loneliness (De Jong Gierveld and van Tilburg, 2010), a six-item-questionnaire (answer categories: “no”, “more or less” and “yes”), with three items each assessing emotional and social loneliness according to Weiss and Bowlby (1980).
Living with loss: A cognitive approach to prolonged grief disorder - Incorporating complicated, enduring and traumatic grief
2023, Behavioural and Cognitive PsychotherapyComplicated grief knowledge and practice: A qualitative study of general practitioners in Ireland
2023, Irish Journal of Psychological Medicine
- 1
These authors are no longer affiliated with the Ludwig-Maximilian-University of Munich.