October 23, 2014 / 7:00 PM / 5 years ago

‘Exposure therapy’ helps patients with prolonged grief

Adding one-on-one sessions focused on reliving the experience of losing a loved one to regular group therapy appears to help more patients with prolonged grief, according to a new study.

Most people who lose a loved one feel stress, grieve and adapt over time. But seven to 10 percent of people get stuck in the grief phase and have persistent yearning for the deceased, difficulty in accepting the death, a sense of meaninglessness, bitterness about the death and difficulty in engaging in new activities, said lead author Richard A. Bryant of the School of Psychology at the University of New South Wales in Sydney, Australia.

People with these symptoms for at least six months may be diagnosed with Prolonged Grief Disorder (PGD), although that is a relatively new diagnosis and still controversial for some psychologists, Bryant said.

“At the moment, many doctors are probably treating them with antidepressants but we know this is quite different from depression,” Bryant told Reuters Health.

Exposure therapy, which emphasizes reliving and processing painful memories and feelings, is the “treatment of choice” for people with post traumatic stress disorder, according to Bryant (see Reuters Health story of July 17, 2013 here: reut.rs/1rrKXJP).

Others have tried to adapt exposure therapy and cognitive behavioral therapy to prolonged grief, which has been successful, though having patients relive the death of a loved one is also a painful process, Bryant said.

“What this study did is try to answer the question: do you really need to do that to treat grief?” he said.

The study included 80 patients with PGD who all received 10 weekly two-hour group therapy sessions using cognitive behavioral therapy (CBT) techniques, like learning to manage avoidance and rumination about the death, learning distraction techniques and cultivating positive memories and new goals for the future.

They also received four individual one-hour therapy sessions. Half of the group continued with CBT techniques, while the other half began exposure therapy focused on facing grief head-on and integrating the loss into memory.

In exposure therapy, the patient spent 40 minutes giving a first-person, present tense account of the death of the person, including their own emotional, mental and physical experiences at the time. In addition to doing this at each of the four individual sessions, they were instructed to do the same exercise as “homework” once a week.

Over the four sessions, therapists had the patients hone in on particularly painful aspects of the experience to be sure they were engaging fully.

Over the course of the study, patients in the exposure group experienced greater decreases in prolonged grief symptoms, decreases in depression symptoms and increases in psychological functioning than the comparison group that got CBT alone.

By the final therapy sessions, six people in the exposure therapy group still qualified for a PGD diagnosis, compared to 13 in the CBT-alone group.

“Quite emphatically the findings demonstrated that patients who received (exposure therapy) did markedly better,” Bryant said.

“One of the ironies, the paradoxes about prolonged grief is that they are yearning for the deceased, but also engaged in avoidance,” he said. “The loved one may have died many years earlier and they’ve never really gone back and felt about it. Some people may visit the grave site every day, may set meals for the loved one every night.”

Past research suggests that some 10 percent of bereaved people experience PGD, Bryant and his colleagues write in JAMA Psychiatry. That would translate to about one million new cases each year in the United States alone.

Since PGD is a new diagnosis, it is hard to predict who will experience grief and adapt and who will not be able to adapt, but in general those who experience prolonged grief were very emotionally dependent on the deceased, he said.

It seems more likely to occur after certain kinds of losses, such as after a suicide or the sudden and unanticipated death of a child, said Dr. Sid Zisook of the University of California, San Diego School of Medicine.

Zisook, who was not involved in the new study, studies treatments for “‘complicated grief,” another name for PGD.

“(Complicated grief) causes great pain, interferes with ongoing life and tends to remain present for prolonged periods in the absence of treatment,” Zisook told Reuters Health by email. “We recommend seeking support from family, friends and spiritual leaders (if consistent with the person’s beliefs and life style) and also seeking professional help.”

In his program, patients with CG receive about 20 weeks of therapy sessions, and some start to see improvements in the first few weeks, he said.

Many Hospices now provide bereavement care and be a valuable resource, he said.

“If I feel that years have gone by and I still can’t deal with this, I should be findings a therapist who can give me CBT,” Bryant said. “People who really want to be helping people come unstuck and develop better adaptation, emotionally engaging with memories of the death, as painful as that may be, does help.”

SOURCE: bit.ly/1s2kpii JAMA Psychiatry, online October 22, 2014.

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