When Grief Lingers: Exploring PGD, CBT, and the Search for Understanding
I have written about the need for research in the field of grief in the article ‘Why We Should Research Grief’. Hopefully these studies can inform public policy and allocate resources towards supporting individuals particularly in the acute stages of their grief. I am uncomfortable with broad-brush assumptions being taken from worthwhile research and being scaled up to apply to everything we call grief. It may be churlish to point out that not all losses and therefore grief are the same…but it does need pointing out. I realise that once we bring some relativity to the grief it can feel like we are elevating our lived experience above others. This is not done to diminish other people's suffering. Ultimately it must be recognised that some people’s lived experience in a particular domain is far worse than most. Lived experience is not a competition, and some competitions you really do not want to win (see this article).
Academic Research has its own style
Research papers in science are formatted and presented in a way to allow other researchers to understand and be able to repeat the research and obtain similar results. Some of this formatting and presentation of results means that many acronyms and symbols are used that most people will not initially understand. Psychological research papers can appear to contain an excessive amount of this formatting. Though I have tried to limit this use of acronyms in this article, anything discussing this type of research will have to use one or two for the sake of brevity.
The other issue for the lay reader is the number of statistics that are utilised to look for patterns in the data that is collected. Statisticians are probably some of the most overlooked yet important people in this type of research. Proving that your results mean something important can often include statistical techniques that are highly specialised. Generally, researchers are looking for trends in their data that can prove that their treatment, if used, is better than: A) doing nothing, and B) current therapies (if available).
Participating in Studies
I recently applied to take part in a study conducted by the University of New South Wales (UNSW) on using cognitive behavioural therapy (CBT) to help treat Prolonged Grief Disorder (PGD). What caught my attention about this study was the fact it was isolating participants with PGD. I have discussed PGD in the article ‘Prolonged Grief Disorder and COVID-19’. This is a diagnosis that, arguably, could be applied to most people who lose a child. While most participants might not have experienced this type of loss, the study still has the potential to help parents who have lost a child.
As you read on, I would hope it is clear to the reader that I am not trying to promote a particular type or method to deal with grief. I want to raise awareness of what is out there and the different types of study associated with grief.
What is CBT?
CBT came from the USA during the 1960s and 1970s. The psychiatrist Aaron T. Beck played a pivotal role by developing Cognitive Therapy. Initially, by focusing on treating depression through identifying and then modifying negative automatic thoughts and dysfunctional core beliefs. Around the same period, psychologist Albert Ellis developed Rational Emotive Behaviour Therapy (REBT), another highly influential cognitive-behavioural approach. CBT as we know it today evolved as these two strategies were progressively combined with established techniques from behavioural therapy.
CBT operates as a form of psychotherapy centred on the understanding that our thoughts (cognitions), feelings (emotions), and actions (behaviours) are deeply interconnected and influence one another. The therapy focuses on helping individuals identify, analyse, and change unhelpful thinking patterns and behaviours causing their psychological distress. With their therapist, individuals concentrate on the problems, thoughts, feelings, and behaviours that are happening in life at that moment, rather than dwelling extensively on their distant past or childhood. Through this process they learn practical skills that can challenge negative thoughts, develop more effective coping mechanisms, and ultimately improve their emotional regulation in response to life's challenges. CBT has been shown to be effective for anxiety, depression, and PTSD.
Grief -focused Cognitive Behavioural Therapy (G-CBT)
Grief-focused Cognitive Behavioural Therapy (G-CBT) is a specialised approach that adapts CBT principles to assist individuals experiencing PGD, where the natural grieving process has become intensely painful and significantly impairing function long after a loss. G-CBT targets the specific unhelpful thought patterns and behaviours that maintain this debilitating state, helping individuals identify and challenge distressing cognitions such as excessive guilt, catastrophic thoughts about the future without the deceased, or persistent difficulty accepting the reality of the death. If you have lost a child, or know someone who has, this may look familiar. Simultaneously, G-CBT addresses key behaviours like the avoidance of grief reminders (people, places, memories) through techniques like gradual exposure, while also using behavioural activation to counteract withdrawal and gently encourage re-engagement with meaningful activities, social connections, and routines. This therapy is thought to help individuals with the processing and integration of the loss, enabling individuals to adapt to life after the death and move beyond a state of chronic, impairing grief.
Trial is currently oversubscribed
Unfortunately, the trial was oversubscribed. I and others all received emails telling us we would be placed on a waiting list for possible future participation. On the one hand, I was disappointed as I was curious about the process and therapy; on the other hand, it showed me that out there, in the rest of the world, many people are looking for assistance in overcoming the loss of a loved one. This project will hopefully help those involved and go on to inform how we can deal with these issues as a society.
Anything that helps
Some grief we can experience in life is catastrophic. As a society we have had to deal with this since the dawn of humanity. It still does not make things easier. As our societies have progressed, we will need to develop how we can support each other in something that will affect us all at some point in our lives.
Further information
I have included a summary of a meta-analysis on G-CBT for any interested readers below. A meta-analysis statistically combines results from multiple independent studies exploring the same question, in this case, G-CBT's effectiveness as a treatment. This provides a more reliable estimate of the overall effect than any individual study can. This is accomplished by examining and combining the findings from various research articles.
I have also included a link to a short 10-minute interview with Professor Richard Bryant who is an expert in this field and runs the Traumatic Stress Clinic at UNSW.
Interview
ABC Radio Interview ‘What is prolonged grief disorder and how is it treated’
Summary of the research paper Grief-Focused Cognitive Behavioral Therapies for Prolonged Grief Symptoms: A Systematic Review and Meta-Analysis created by Gemini Advanced
Here is a summary of the paper "Grief-Focused Cognitive Behavioural Therapies for Prolonged Grief Symptoms: A Systematic Review and Meta-Analysis"
Reference: Komischke-Konnerup, K. B., Zachariae, R., Boelen, P. A., Marello, M. M., & O'Connor, M. (2024). Grief-focused cognitive behavioral therapies for prolonged grief symptoms: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 92(4), 236–248. https://doi.org/10.1037/ccp0000884
Background:
Prolonged Grief Disorder (PGD) is a recognised mental health condition characterized by intense and persistent grief reactions, such as longing for the deceased and preoccupation with the loss. Cognitive Behavioural Therapies (CBTs) focused on grief are thought to be effective treatments, but a comprehensive overview was needed.
Objective:
This study aimed to systematically review and analyse data from randomized controlled trials (RCTs) to determine the overall effectiveness of grief-focused CBTs in reducing PGD symptoms in bereaved adults. It also assessed the impact of these therapies on secondary outcomes like depression, post-traumatic stress disorder (PTSD), and anxiety symptoms.
Methods:
Researchers systematically searched major scientific databases (Pubmed, APA PsycInfo, Web of Science, Embase). They included 22 RCTs involving a total of 2,602 bereaved adults (average age 49 years). Statistical meta-analysis was used to calculate the overall effect size (Hedges's g) of CBTs compared to control groups (like waitlists, supportive counselling, or other therapies). Factors potentially influencing the effects (moderators), the risk of bias in the included studies, and the overall quality of the evidence were evaluated.
Key Findings:
Grief-focused CBTs showed a statistically significant medium-sized positive effect on reducing PGD symptoms immediately after treatment compared to control groups. This effect appeared large at follow-up assessments (ranging from 1 to 12 months later), although fewer studies included follow-up data. CBTs also led to significant small-to-medium reductions in symptoms of PTSD, depression, and anxiety immediately after treatment. The positive effects on PGD symptoms remained consistent even when accounting for potential outliers or publication bias. No specific characteristics (like the type of CBT component used, individual vs. group format, digital vs. face-to-face delivery, or participant demographics) were found to significantly moderate the treatment effect. However, there was considerable variation (heterogeneity) in the results across the different studies. The overall quality of the evidence from the meta-analysis was rated as moderate, mainly due to the heterogeneity and some limitations in the included studies (e.g., risk of bias in measuring outcomes).
Conclusion:
The review suggests that grief-focused CBTs are an efficacious treatment for reducing PGD symptoms in adults. They also help alleviate associated symptoms like PTSD, depression, and anxiety. These therapies can be delivered effectively through various methods, including individual or group sessions, and either online or face-to-face. Caution is advised when generalising the findings due to the significant variability between studies and some methodological limitations. Further research is needed to determine which specific CBT approaches work best for whom, understand how these therapies produce change, and establish the optimal timing for intervention.