Treating Prolonged Grief Disorder: A 2-Year Follow-Up of a Randomized Controlled Trial
Abstract
BACKGROUND: Prolonged grief disorder (PGD) causes significant impairment in approximately 7% of bereaved people. Although cognitive-behavioral therapy (CBT) has been shown to effectively treat PGD, there is no evidence of long-term effects of CBT. OBJECTIVE: To determine the long-term efficacies of CBT with exposure or CBT without exposure in treating PGD by assessing outcome at 2 years. METHODS: A randomized controlled trial of PGD patients (N = 80) attending an outpatient clinic took place between September 2007 and June 2010, and a 2-year follow-up occurred between December 2009 and October 2012. All patients received 10 weekly 2-hour group therapy sessions that comprised CBT techniques. Patients also received 4 individual sessions in which they were randomly allocated to receive exposure therapy (CBT/Exposure) for memories of the death or supportive counseling (CBT). Prolonged grief disorder was assessed by clinical interview using the Complicated Grief Assessment. Severity of PGD, the primary outcome, was assessed using the Inventory of Complicated Grief. RESULTS: Intent-to-treat analyses indicated a significant linear time × treatment condition interaction effect at 2 years (B = -0.63; SE = 0.26; t₂₂₅ = -2.44; P = .02; 95% CI, -1.14 to -0.12), indicating that CBT/Exposure led to greater reductions in PGD than CBT. Further, the linear between-group effect size at the 2-year follow-up was 1.15. CONCLUSIONS: Exposure therapy in the course of CBT leads to greater reduction in symptoms of PGD than CBT without exposure, and this additive gain extends 2 years after treatment is complete. To achieve optimal treatment gains in patients with PGD, therapists should encourage some form of exposure therapy to memories of the death. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry identifier: ACTRN12609000229279.
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Exposure treatments more effectively reduced complicated grief symptoms when added to CBT than CBT alone.
“and more effectively reduced CG symptoms when added to cognitive behavioral treatment (CBT) than CBT alone (Bryant et al., 2014; Bryant et al., 2017).”
From Emotion Regulatory Strategies in Complicated Grief: A Systematic Review (2021) · cites this paper as Bryant et al., 2017
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Johannsen, M., Damholdt, M. F., Zachariae, R., Lundorff, M., Farver-Vestergaard, I., & O'Connor, M. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.04.065 · Cited by 214 · see citing works
Emotion Regulatory Strategies in Complicated Grief: A Systematic Review
Eisma, M. C., & Stroebe, M. S. (2021) · Behavior Therapy · doi:10.1016/j.beth.2020.04.004 · Cited by 152 · see citing works
“, 2015), and more effectively reduced CG symptoms when added to cognitive behavioral treatment (CBT) than CBT alone (Bryant et al., 2014; Bryant et al., 2017).”
BackgroundAn open trial of meaning-centered grief therapy: rationale and preliminary evaluation
Lichtenthal, W. G., Catarozoli, C., Masterson, M., Slivjak, E., Schofield, E., Roberts, K. E., Neimeyer, R. A., Wiener, L., Prigerson, H. G., Kissane, D. W., et al. (2019) · Palliative and Supportive Care · doi:10.1017/s1478951518000925 · Cited by 88 · see citing works
“The theoretical foundation is largely informed by the cognitive-behavioral model, which has demonstrated efficacy in improving prolonged grief, mood, and anxiety (Boelen, 2006; Bryant et al., 2017; Tolin, 2010).”
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Meichsner, F., O’Connor, M., Skritskaya, N., & Shear, M. K. (2020) · The American journal of geriatric psychiatry · doi:10.1016/j.jagp.2019.12.010 · Cited by 45 · see citing works
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Commentary on Evidence in Support of a Grief Related Condition as a DSM Diagnosis
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“Studies by Boelen, de Keijser, van den Hout, and van den Bout (2007) and Bryant et al. (2014) further support the effectiveness of exposure to the story of the death, as well as long‐term efficacy (Boelen et al., 2007; Bryant et al., 2014; Bryant et al., 2017).”
BackgroundSupporting the bereaved in greatest need: We can do better
Lichtenthal, W. G. (2018) · Palliative & Supportive Care · doi:10.1017/s1478951518000585 · Cited by 34 · see citing works
“Although research has demonstrated the efficacy of several therapeutic approaches, including pharmacotherapy interventions, none are universally efficacious (Boelen, 2016; Boelen et al., 2011; Bryant et al., 2017; Kissane et al., 2006; Mancini et al., 2012; Sandler et al., 2010; Shear et al., 2016).”
BackgroundProlonged grief and depression: A latent class analysis
Kokou‐Kpolou, C. K., Park, S., Lenferink, L. I. M., Iorfa, S. K., Fernández‐Alcántara, M., Dérivois, D., & Cénat, J. M. (2021) · Psychiatry Research · doi:10.1016/j.psychres.2021.113864 · Cited by 32 · see citing works
Rumination, worry and negative and positive affect in prolonged grief: A daily diary study
Eisma, M. C., Franzen, M., Paauw, M., Bleeker, A., & Rot, M. A. H. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2635 · Cited by 36 · see citing works
Prolonged grief disorder in Chinese Shidu parents who have lost their only child
Zhang, H.-H., Shang, Z.-L., Wu, L.-L., Sun, Z.-E., Zhang, F., Sun, L.-N., Zhou, Y.-G., Wang, Y., & Liu, W.-Z. (2020) · European Journal of Psychotraumatology · doi:10.1080/20008198.2020.1726071 · Cited by 27 · see citing works
“Exposure therapy with cognitive behaviour therapies (CBT) by addressing the avoidance behaviour and grief pain has proved to be an effective treatment by many randomized clinical trials (Bryant et al., 2014, 2017; Rosner, Bartl, Pfoh, Kotoucova, & Hagl, 2015; Rosner, Pfoh, Kotoucova, & Hagl, 2014).”
MethodTay, A., Rees, S., Tam, N., Kareth, M., & Silove, D. (2018) · Psychological Medicine · doi:10.1017/s0033291718002027 · Cited by 22 · see citing works
“Although there is some evidence in support of the efficacy of cognitive behavioral interventions in treating complicated bereavement in nonrefugee populations (Rosner et al., 2014; Bryant et al., 2017), no culturally adapted interventions of this type have been systematically trialled amongst refugees (Murray et al.”
BackgroundPredictors of treatment response for cognitive behaviour therapy for prolonged grief disorder
Bryant, R. A., Kenny, L. M., Joscelyne, A., Rawson, N., Maccallum, F., Cahill, C. M., & Hopwood, S. (2017) · European Journal of Psychotraumatology · doi:10.1080/20008198.2018.1556551 · Cited by 27 · see citing works
“Reinforcing the role of exposure was a study that reported that CBT that involved exposure therapy of death memories led to greater treatment outcomes than CBT without exposure (Bryant et al., 2014, 2017).”
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Acierno, R., Kauffman, B. Y., Muzzy, W., Tejada, M. H., & Lejuez, C. (2021) · The American journal of hospice & palliative care · doi:10.1177/1049909121989021 · Cited by 20 · see citing works
“A number of interventions targeting Persistent Complex Bereavement Disorder exist.(28-41) While some intervention components (e.”
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Self-citationLetter Writing as a Clinical Tool in Grief Psychotherapy
Larsen, L. H. (2022) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228211070155 · Cited by 22 · see citing works
“…empty chair technique, involving imaginary conversations with the deceased (Field & Horowitz, 1998; Paivio & Greenberg, 1995), and other exercises involving imaginary conversations, e.g., letter writing assignments (Boelen et al., 2013; Bryant et al., 2014; 2017; Rosner et al., 2011; Shear, 2017).”
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“Specifically, Rosner et al. (2014) and Rosner et al. (2015) tested the efficacy of a cognitive–behavioral grief therapy (CBGT) in 20 to 25 sessions, whereas Bryant et al. (2014) and Bryant et al. (2017) showed positive effects of a treatment consisting of 10 CBGT and 4 exposure therapy sessions.”
Schiele, M. A., Costa, B., Abelli, M., Martini, C., Baldwin, D. S., Domschke, K., & Pini, S. (2018) · The World Journal of Biological Psychiatry · doi:10.1080/15622975.2018.1430374 · Cited by 20 · see citing works
“For the treatment of CG, effective psychotherapeutic and pharmacological (e.g., Shear et al. 2005; Hensley et al. 2009; Glickman et al. 2016; Shear et al. 2016; Bryant et al. 2017) interventions are available.”
MethodChallenges in Grief-Focused Cognitive Behavior Therapy for Prolonged Grief Disorder
Maccallum, F., Dawson, K., Azevedo, S., & Bryant, R. A. (2023) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2023.10.002 · Cited by 16 · see citing works
Self-citationCompetitive neurocognitive processes following bereavement
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“This observation does not undermine the utility of reliving strategies in the treatment of PGD because evidence indicates that treatment outcomes are improved when reliving is given priority (Boelen et al., 2007; Bryant et al., 2014, 2017; Eisma et al., 2015).”
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Adaptive Disclosure: Theoretical Foundations, Evidence, and Future Directions
Darnell, B. C., Vannini, M. B. N., Grunthal, B., Benfer, N., & Litz, B. T. (2022) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-022-00264-4 · Cited by 8 · see citing works
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On the concept, taxonomy, and transculturality of disordered grief
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Psychosocial Issues and Bereavement
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“Letter writing as a therapeutic tool is used in effective grief therapy interventions for adults (Boelen et al., 2013; Bryant et al., 2017; Rosner et al., 2011; Wojtkowiak et al., 2021).”
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Treatments for Prolonged Grief Disorder: A Systematic Review and Network Meta-Analysis
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Is Prolonged Grief Disorder an Emotional Disorder?
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“In addition, PGD symptoms significantly decrease when exposure to loss-related stimuli is implemented (Boelen et al., 2007; Bryant et al., 2017; Eisma et al., 2015), indicating that avoidance of loss-related stimuli may indeed play a role in the maintenance of PGD. Emotion-motivated avoidant coping…”
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“Cognitive Behavioral Therapy (CBT) has been proven to be an effective treatment for somatoform disorders (Liu et al., 2019; Kroenke & Swindle, 2000) and prolonged grief (Boelen, 2005; Bryant et al., 2017; Rosner et al., 2011).”
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Cognitive Behavioral Treatments for Prolonged Grief: Introduction to the Special Feature
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Group Vs Individual Grief-Focused Cognitive Behavioral Therapy for Older Adults
Komischke-Konnerup, K. B., Boelen, P. A., Maccallum, F., & O’Connor, M. (2026) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2025.4106
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- Authors
- Bryant, R. A., Kenny, L., Joscelyne, A., Rawson, N., Maccallum, F., Cahill, C., Hopwood, S., & Nickerson, A.
- Affiliations
- UNSW Sydney (AU)
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2017-12-27
- Volume
- 78
- Issue
- 9
- Pages
- 1363-1368
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2608368258
- Cited by
- 48
- References
- 0
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 7 · 2023: 6 · 2022: 6 · 2021: 3 · 2020: 8 · 2019: 4 · 2018: 4 · 2017: 1
- FWCI
- 5.75
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Anthropology › Death, Funerary Practices, and Mourning
- Keywords
- prolonged grief disorder, complicated grief, cognitive behavioral therapy, exposure therapy, bereavement, long-term treatment efficacy, group therapy, memory of death, supportive counseling
- MeSH terms
- Follow-Up Studies, Grief, Humans, Implosive Therapy, Male, Middle Aged, Psychiatric Status Rating Scales, Cognitive Behavioral Therapy, Treatment Outcome
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