In January 1997, a panel of experts in the areas of bereavement, trauma, and
psychiatric nosology convened to discuss the need for diagnostic criteria
for complicated grief, or what we now prefer to call Traumatic Grief (Prigerson
et al., 1999). The workshop began with a review of a series of studies of
independent samples of bereaved people demonstrating that symptoms of separation
distress (e.g., yearning, searching for the deceased, excessive loneliness
resulting from the loss) form a unidimensional cluster with symptoms of Traumatic
distress (e.g., intrusive thoughts about the deceased feelings of numbness,
disbelief about the loss, being stunned or dazed, fragmented sense of security
and trust). Notably, this cluster is distinct from depressive and anxiety
symptom clusters (Prigerson, Frank, et al., 1995; Prigerson, Maciejewski,
et al., 1995; Chen, et al., 1999; Prigerson, Shear, et al., 1996; Prigerson,
Bierhals, et al., 1996). In additional analyses, this cluster of symptoms
lasts several years among a significant minority of bereaved subjects (Prigerson,
et al., in press; Prigerson, Bierhals, et al., 1997; Prigerson, Shear, et
al., 1997; Prigerson, Bierhals, Wolfson, et al., 1997). Furthermore, these
symptoms, unlike depressive symptoms, do not respond to interpersonal psychotherapy
either alone or in combination with a tricyclic antidepressant (Pasternak
et al., 1991; Reynolds et al., 1999). Finally, these symptoms predict substantial
morbidity over and above depressive symptoms (Prigerson, Frank, et al., 1995;
Prigerson, Maciejewski, et al., 1995; Chen et al., 1999; Prigerson, Shear,
et al., 1996; Prigerson, Bierhals, et al., 1996; Prigerson, Bierhals, et
al., 1997). The panel concluded that the evidence justified the development
of diagnostic criteria for Traumatic Grief. Participants then discussed the
symptoms that should be included in a diagnosis and, ultimately, proposed
a consensus set of criteria for Traumatic Grief (see the appendix). A recent
study provided preliminary empirical support for most of the proposed symptoms
(Prigerson et al., 1999). Prigerson and colleagues are currently collecting
field trial data to determine the optimal mix of symptoms and their severity,
as well as the duration, that provide the most accurate diagnosis for Traumatic
With consensus diagnostic criteria for Traumatic Grief in hand to serve as
the dependent variable in studies of risk factors, we believe we are in a better
position than before to identify bereaved individuals at risk. In addition,
we believe that diagnostic criteria for Traumatic Grief can lead to a better,
more refined understanding of the specific grief symptoms to target for therapy.
Central to the syndrome of Traumatic Grief is separation anxiety, and for the
purposes of this review of potential treatments, we conceive of Traumatic Grief
as an adult type of separation anxiety disorder with traumatic features related
to the loss.
Psychotherapy of Traumatic Grief
With this background, we reviewed studies of potential relevance to Traumatic
Grief that were controlled clinical trials of psychotherapy with outcome
measures. As no studies of diagnosed Traumatic Grief per se are available,
we searched for psychotherapy trials of separation anxiety disorders, pathologic
grief, or samples of high-risk bereaved persons, all of which we believe
have a close relationship to Traumatic Grief. In addition, we searched for
treatment studies where some assessment of Traumatic Grief was completed
and ad hoc observations were made. The logic for drawing on studies of separation
anxiety disorder in childhood depended on our assumption that Traumatic Grief
is a type of separation anxiety disorder. The logic for reviewing studies
of pathologic grief depended on the close historical relationship of the
concept of pathologic grief to the new criteria for Traumatic Grief and their
common foundations in separation distress. Finally, the logic of including
studies of high-risk bereaved persons was based on the assumption of a close
relationship between high risk and the existence of pathologic grief in many
persons in the sample. Although the assumptions made in this review are compelling
to us, we recognize that our conclusions will need confirmation from systematic
study of persons diagnosed with Traumatic Grief.
Specifically, we review a study of the psychotherapeutic treatment of anxiety
disorders in children, including a subgroup with separation anxiety disorder.
Also, we review several, psychodynamically oriented and behavioral studies
of psychotherapy for "pathologic grief" in adults. We include one
controlled study of group therapy. To round out these controlled observations,
we summarize incidental observations from several studies about the treatment
of persons with high-symptom scores for Traumatic Grief.
The literature contains three controlled studies of crisis intervention for
acutely bereaved adults done during the 1970s. Crisis intervention is a brief
psychotherapy that focuses on current problems and the emotional crisis caused
by a stressor, the paradigm for which was bereavement (Caplan, 1964). Two of
these studies found positive results for the intervention (Gerber, Wiener,
Battin, & Arkin, 1975; Raphael, 1977). The study that showed negative results
(Polak, Egan, & Bandenbergh, 1975) treated everyone regardless of diagnosis
or risk, and the therapy was minimally and loosely conceived. Both of these
features of the study may have contributed to the negative results.
One study by Raphael (1977) of a 3-month, psychodynamically oriented, preventive
intervention for 31 high-risk, acutely bereaved widows during the initial stages
of grief is particularly notable. High risk was defined in terms of perceived
non-supportiveness of the bereaved person's social network, untimely and unexpected
anger and guilt-provoking aspects of the death, a highly ambivalent marital
relationship, and the presence of concurrent life crises. The treatment group
demonstrated considerable reduction of symptom scores on Goldberg's General
Health Questionnaire compared with the controls at follow-up 13 months after
the loss. Specifically, the treatment group improved more than controls on
measures of anxious symptoms, depressive symptoms (including neurovegetative
symptoms), and somatic symptoms.
Brief, Dynamic Psychotherapy
Additional studies have investigated other specific therapies for "pathologic" or "complicated" grief.
For example, Horowitz and colleagues (Horowitz, Marmar, Weiss, DeWitt, & Rosenbaum,
1984) treated 33 bereaved women and 2 bereaved men with brief dynamic psychotherapy.
Both the treatment group and the comparison group of 37 field participants,
who were untreated, showed significant stress-specific and general symptomatic
relief over the course of study. The treatment group started with a higher
intensity of intrusive, avoidant, anxious, and depressive symptoms than the
comparison group and declined faster toward the end of treatment. Approximately
1 year after the loss, the treatment group attained improved levels not significantly
different from the field controls. One exception to this pattern was the reponse
of avoidant symptoms, which declined from high, initial levels in the treatment
group (M = 17.6) but ended the year in patients at about the same initial level
of the comparison group (7.1 in patients at year end vs. 7.5 initially in comparisons),
who had declined significantly to even lower levels over the year (M = 3.3).
Still, the authors note in their discussion that the major difference between
the two groups over time was a decline in the patients' avoidance of themes
and emotions evoked by the death.
In a related study, Marmar and colleagues compared brief dynamic
psychotherapy to mutual-help group treatment led by specially trained nonclinicians
(Marmar, Horowitz, Weiss, Wilner, & Kaltreider, 1988). Both groups experienced
reductions in stress-specific and general symptoms as well as improvement in
social and work functioning. The symptomatic improvement emerged as a statistical
trend at the completion of treatment (12 weeks) and became significant at the
time of 4-month follow-up after treatment, leaving a question of whether it
was a delayed treatment effect.
- Jacobs, Selby, Prigerson, Holly, Screening, Psychotherapy of Traumatic
Grief: A Review of Evidence for Psychotherapeutic Treatments; Death Studies;
Sept 2000; Vol. 24; Issue 6.
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #8
The preceding section contained information
about psychotherapy of traumatic grief. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
According to Jacobs, what is central to the syndrome of Traumatic Grief? Record the letter of the correct answer