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Grief: Treating Life Trauma Issues & Death
Grief continuing education social worker CEUs

Section 22
Psychotherapy of Traumatic Grief

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Traumatic Grief
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 Grief.

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.

Crisis Intervention
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.

Personal 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.

Peer-Reviewed Journal Article References:
Beller, J., & Wagner, A. (2018). Loneliness, social isolation, their synergistic interaction, and mortality. Health Psychology, 37(9), 808–813.

Bellet, B. W., LeBlanc, N. J., Nizzi, M.-C., Carter, M. L., van der Does, F. H. S., Peters, J., Robinaugh, D. J., & McNally, R. J. (2020). "Identity confusion in complicated grief: A closer look": Correction. Journal of Abnormal Psychology, 129(6), 543.

Captari, L. E., Riggs, S. A., & Stephen, K. (2020). Attachment processes following traumatic loss: A mediation model examining identity distress, shattered assumptions, prolonged grief, and posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Online Continuing Education QUESTION 22
According to Jacobs, what is central to the syndrome of Traumatic Grief?  Record the letter of the correct answer the CEU Test.

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