REVIEW

CURRENT
OPINION Treatment for complicated grief: state of the
science and ways forward
Bettina K. Doering a, and Maarten C. Eisma b,

Purpose of review
There is increasing recognition that a minority of bereaved persons experiences persistent and disabling
grief symptoms, also termed complicated grief. We review currently proposed criteria for complicated grief
in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the International Statistical
Classification of Diseases and Related Health Problems (ICD-11), highlight controversies with regard to
establishing complicated grief as a psychiatric disorder, summarize recent complicated grief treatment
research within a cognitive behavioral treatment framework, and establish a novel and systematic research
agenda for complicated grief treatment.
Recent findings
Clinicians should be wary of overdiagnosis and misdiagnosis of complicated grief. Recent changes to
definitions of complicated grief may threaten generalizability and clinical application of research findings.
Universal treatment, treatment for at-risk groups and preventive complicated grief treatment appear
ineffective. Although medication is often prescribed to bereaved persons, evidence for its effectiveness is
equivocal. Face-to-face and internet-based cognitive behavioral therapy techniques appear most effective in
targeting complicated grief. However, little is known about what, how, and for whom treatment works best.
Summary
In light of these findings, we recommend systematic investigation of: what works best in complicated grief
treatment, by conducting well designed, stepped effectiveness trials and treatment component dismantling
studies; how it works, by conducting investigations on therapeutic theories and examining mediators of
therapeutic change; and for whom it works, by examining potential moderators of treatment effects.
Keywords
cognitive behavioral therapy, complicated grief, persistent complex bereavement disorder, prolonged
grief disorder, psychotherapy

INTRODUCTION & &

Bereavement is a universal experience and a major
life-stressor that is associated with adverse con-
sequences for mental and physical health, including
&
increased mortality [1,2 ], and substantial societal
costs [3]. Although most people recover from a loss
without professional help, a minority of bereaved
persons across cultures suffers from severe and dis-
abling grief for a prolonged period of time [4].
Various names for this condition have been pro-
posed, such as complicated grief, pathological grief,
and prolonged grief disorder, which all have slightly
different defining criteria [5]. In the current review,
the term ‘complicated grief’ will be used to describe
these disturbed grief patterns. Previous research has
investigated complicated grief, its predictors and
correlates and has accumulated evidence that
complicated grief represents a distinct nosologic
and diagnostic entity [4] that requires specific
treatments [6 ,7,8 ], although it had not been
included in the Diagnostic and Statistical Manual
of Mental Disorders (DSM)-IV or the International
Statistical Classification of Diseases and Related
Health Problems (ICD)-10. The present article
reviews proposed diagnostic criteria for complicated
a
Division of Clinical Psychology & Psychotherapy, Department of Psy-
chology, Philipps-University Marburg, Marburg, Germany and bHealth
Psychology Group, Division of Applied Health Sciences, University of
Aberdeen, Aberdeen, UK
Correspondence to Bettina K. Doering, Division of Clinical Psychology &
Psychotherapy, Department of Psychology, Philipps-University Marburg,
Gutenbergstraße 18, D-35037 Marburg, Germany.
Tel: +49 6421 28 24 083; e-mail: doeringb@staff.uni-marburg.de

Bettina K. Doering and Maarten C. Eisma contributed equally to the
article.
Curr Opin Psychiatry 2016, 29:286–291
DOI:10.1097/YCO.0000000000000263

www.co-psychiatry.com Volume 29  Number 5  September 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 The new criteria for complicated grief proposed in
ICD-11 and DSM 5 will stimulate research, but we
should be wary of overdiagnosis and misdiagnosis.
 Varying diagnostic criteria may negatively impact the
comparability of previous and future research and
translation of research findings to clinical practice.
 Recent trials using CBT techniques demonstrated
promising results for comprehensive complicated grief
treatments, specific treatment components, and brief
online complicated grief treatments.
 Future research needs to establish what complicated
grief treatments are most effective for whom and what
working mechanisms explain complicated grief
treatment effects.
grief, highlights some controversies with regard
to establishing complicated grief as a psychiatric
disorder, and reviews recent research on adult com-
plicated grief treatment to provide concrete recom-
mendations for future research.
NEW DIAGNOSTIC CRITERIA
The DSM 5 conceptualizes complicated grief as a
condition for further study named persistent com-
plex bereavement disorder (PCBD) [9]. DSM 5 speci-
fies the following criteria for PCBD: after the death
of a close other, the bereaved person experiences
clinically relevant and disabling distress for at least
12 months; main symptoms include yearning,
emotional pain or preoccupation with the deceased.
Additional criteria are reactive distress to the death
(e.g., difficulties accepting the death, avoidance of
loss reminders) and symptoms indicative of social or
identity disruption (e.g., feeling that a part of one-
self died with the deceased; difficulty engaging in
social activities). Cultural norms should be con-
sidered when differentiating normal grief from
PCBD. In response to the publication of DSM 5,
several PCBD assessment instruments have been
developed (e.g., [10,11]).
ICD-11 will probably include ‘Prolonged Grief
Disorder’ as a complicated grief diagnosis and clas-
&
sify it as a stress-related disorder [12 ]. However,
diagnostic criteria are likely different from PCBD
in the DSM 5, especially the timing criterion:
ICD-11 may allow a diagnosis as early as 6 months
postloss, if no other normative time frame is estab-
lished in the bereaved person’s cultural or social
norms [13]. In spite of the different timing criterion,
other main symptoms (yearning and preoccupa-
tion) and additional symptoms (anger about the
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Treatment for complicated grief Doering and Eisma
loss, difficulties accepting the death) appear com-
parable with DSM 5 criteria for PCBD. It remains to
be seen whether treatment trials of complicated
grief will embrace DSM 5 or ICD-11 criteria and
how this will impact the treatment of complicated
grief in clinical practice.
GRIEF – NORMAL OR ABNORMAL?
Although the new diagnostic criteria for compli-
cated grief will certainly stimulate research and draw
more attention to severe difficulties some people
experience after bereavement, efforts to define com-
plicated grief have not been without criticism. The
fact that 75% of a culturally diverse lay sample but
only 43% of a sample of psychotherapists believe
that there are manifestations of grief that can be
classified as mental disorders, illustrate that many
practitioners are wary of medicalizing a normal
response to a major life-stressor [14,15]. As bereave-
ment is a universally experienced life-event and
symptoms of acute grief may be difficult to differ-
entiate from complicated grief based on duration or
phenomenology alone ([5], but see also [2 ,16]),
&
clinicians should indeed be cautious of overdiagno-
sis. This concern is substantiated by a recent study
showing frequent misdiagnosis of prolonged grief
disorder based on case descriptions that represent
&
normal grief patterns [17 ]. Although there is great
variability in reactions to bereavement, resulting in
different grief trajectories, only a minority of
mourners experience persistent high grief levels
[18,19]. Diagnostic concerns are amplified by the
DSM 5 removal of the bereavement exclusion for
major depression [20,21]: it is now possible to diag-
nose a depressive episode at 2 weeks postloss. This
may not only pathologize ‘normal grievers’ but also
misclassify persons at risk of developing compli-
cated grief.
Researchers have also critically discussed the
frequent changes to diagnostic criteria for compli-
cated grief [22,23]. The variability in definitions of
complicated grief in DSM 5, ICD-11, and previous
research could have serious implications for
research and practice. For example, the instrument
currently most often used to assess complicated grief
symptoms in clinical trials, the Inventory of Com-
plicated Grief (ICG) [24] does not correspond
entirely with PCBD criteria. Most notably, DSM 5
has introduced new complicated grief symptoms
(e.g., difficulty in positive reminiscing; maladaptive
self-appraisals) that are not assessed by the ICG. This
makes it difficult to establish whether results from
previous clinical trials generalize to the treatment of
PCBD and may hinder the dissemination of effective
treatments into clinical practice.
www.co-psychiatry.com 287
Psychiatry, medicine and the behavioral sciences
WHAT IS KNOWN ABOUT TREATMENT OF
COMPLICATED GRIEF?
When providing an evaluative review of compli-
cated grief treatment, it is important to consider
the full scope of research on grief interventions.
The most robust finding in systematic reviews and
meta-analyses is that there is no evidence for effects
of universal interventions. Treatment generally
works best when targeting individuals experiencing
marked difficulties adapting to loss (e.g., meeting
&
criteria for complicated grief) [25,26 ,27].
Caution should be exercised in prescribing
medication for complicated grief. Although anti-
depressants are often prescribed to bereaved persons
[28], older evidence for their effectiveness in reduc-
ing complicated grief symptoms is equivocal [29].
Although some studies report positive effects,
these studies often do not employ a randomized
controlled trial (RCT) design [30] or are otherwise
limited in their interpretability (e.g., small sample
sizes and large drop-out rates). However, a large
placebo-controlled trial of citalopram for compli-
cated grief (in combination with psychotherapy
and as stand-alone treatment) has recently been
&&
completed [31 ]. It demonstrates no efficacy of
citalopram as stand-alone treatment for compli-
cated grief, but suggests that adding citalopram to
an effective CBT treatment may alleviate co-occur-
ing depressive symptoms.
Concerning the effectiveness of psychotherapy
in the treatment of complicated grief, systematic
reviews show that there is no positive effect
for preventive treatments of complicated grief
&
symptom levels ([26 ] but see [32]) and only a small
effect for selective interventions for at-risk popu-
lations [25]. A recent trial of cognitive behavioral
therapy (CBT) interventions for persons bereaved
by suicide indeed demonstrated very limited
&
effectiveness [33 ]. Interventions for persons who
meet criteria for complicated grief, however,
achieve at least moderate effect sizes postinter-
&
vention [25,26 ]. Recent research has also demon-
strated that complicated grief is ameliorated
more strongly by treatments that are specifically
tailored to complicated grief than to interventions
that stem from depression treatment such as
&
interpersonal therapy [6 ,34]. This illustrates the
need to further pursue the development and testing
of complicated grief specific interventions. One
treatment that appears particularly promising is
&
CBT for complicated grief [25,26 ]. Although vari-
ous models of complicated grief have been pro-
posed [35,36], and general models of coping with
bereavement are also useful in understanding com-
plicated grief (e.g., [37]), we will use a CBT concep-
tualization of complicated grief [38] to summarize
288 www.co-psychiatry.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
the most recent research within a coherent frame-
work.
COGNITIVE-BEHAVIORAL TREATMENT OF
COMPLICATED GRIEF
In brief, the cognitive-behavioral model of compli-
cated grief [38] proposes that three core processes
explain the occurrence and persistence of compli-
cated grief symptoms: insufficient integration of the
loss with existing autobiographical knowledge [39];
negative global beliefs (about oneself, the world and
the future) and catastrophic misinterpretations of
grief symptoms [39–41]; and anxious avoidance
(i.e., cognitive and overt avoidance of reminders
of the loss) [39,40,42–46] and depressive avoidance
(i.e., avoidance of social, occupational and recrea-
tional activities, and behavioral withdrawal)
[39,41,44,47,48]. Correspondingly, CBT treatments
of complicated grief typically consist of creating a
coherent, meaningful autobiographical narrative
about the loss; challenging negative beliefs and
catastrophic misinterpretations through cognitive
restructuring; gradually confronting persons with
avoided aspects of the loss (e.g., places, objects,
memories) through exposure techniques; and/or
helping people to set new life-goals and engage in
&
new, meaningful activities [12 ,37,38].
These techniques were first successfully applied
in two seminal studies on CBT in bereaved persons.
It was demonstrated that retelling the story about
the loss, imaginal and in-vivo exposure, and iden-
tifying and working toward new life goals can be
effective as part of an integrative complicated grief
treatment [34]. Furthermore, cognitive restructur-
ing and tailored exposure exercises effectively
reduced complicated grief symptoms, although it
may be more beneficial to begin treatment with
cognitive restructuring and end it with exposure
rather than vice versa [7]. Since this pioneering
work, a number of investigations have demon-
strated the effectiveness of CBT techniques for
& & & &
complicated grief [6 ,8 ,32,49,50 ,51,52,53 ]. For
instance, a controlled feasibility study showed that
intensive behavioral activation (e.g., self-monitor-
ing of activities, identification of life goals, and
engaging in new goal-congruent fulfilling activities)
yielded large short-term effects on complicated grief
symptom levels [52]. More recently, the literature on
CBT treatments for complicated grief has been rap-
idly expanding; we will highlight three exciting
new developments.
First, there is a growth of trials providing strin-
gent tests of comprehensive complicated grief treat-
& &
ments [8 ,12 ,49,51]. For example, a previously
successfully tested multicomponent complicated
Volume 29  Number 5  September 2016

grief treatment using CBT techniques (i.e., exposure;
setting new life goals) was tested in a large-scale RCT
with elderly bereaved persons with complicated
grief, showing strong reductions in complicated
grief symptoms and beneficial effects relative to
&
interpersonal therapy at posttreatment [6 ,34].
Second, some researchers have further decon-
structed the effectiveness of treatment components
& &
of CBT treatment of complicated grief [8 ,53 ]. For
instance, a multicomponent CBT treatment, with
cognitive restructuring, rumination management
and goal setting, was found to be less effective than
the same treatment with imaginal exposure at
&
posttreatment and 6-month follow-up [8 ]. Third,
brief CBT treatments via the internet are tested and
&
yield promising results [49,53 ]. For instance, a
6-week e-mail-delivered tailored exposure treatment
resulted in large effects on complicated grief symp-
& &&
tom levels relative to a waitlist control group [53 ].
This is particularly noteworthy, as it may open up
future possibilities for staged treatment models, in
which brief online treatment is offered as a first
option and more intensive psychotherapy is offered
only to those still in need of help after this.
WAYS FORWARD: WHAT, HOW, AND FOR
WHOM COMPLICATED GRIEF
TREATMENTS WORK
Considering that for a long time, most bereavement
psychotherapy interventions yielded few beneficial
effects [25], it is a major accomplishment that so
many recent CBT treatments target complicated
grief effectively. However, even the best treatments
only achieve clinically relevant effects in compli-
cated grief for about half or less of all participants,
which suggests these treatments can be improved.
In order for clients to optimally benefit and for
therapists and researchers to be adequately
informed, we will highlight important gaps in the
complicated grief treatment literature and outline
an ambitious research agenda which can be
summarized very briefly: we need to establish what,
how, and for whom complicated grief treatments
work best.
What treatment works best is difficult to deter-
mine as results across investigations cannot easily be
compared. Psychotherapeutic treatments for com-
plicated grief are heterogeneous in their use of treat-
ment components and are delivered through
varying modalities (e.g., internet and face-to-face)
and formats (e.g., individual, group, and family).
Treatment effectiveness studies also commonly dif-
fer in other respects, including complicated grief
diagnostic criteria and treatment outcome assess-
ment. Furthermore, trials often test the short-term
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Treatment for complicated grief Doering and Eisma
effectiveness of novel therapies in relatively small
samples, leading to a patchwork of preliminary
evidence rather than a broad evidentiary base for
& &
a few clearly defined treatments (but see [6 ,49,50 ]).
Generalizability of results may also be limited as
samples predominantly comprise higher educated
&
female adults from Western countries ([26 ], but see
[47,54]).
To establish what works when treating compli-
cated grief, future research should aim at program-
matically and systematically assessing short-term
and long-term effects of existing treatments show-
ing promising effects using adequately powered
multicenter RCTs. The work of Shear et al.
& &
[6 ,12 ,34] can be considered exemplary, as it first
evaluated the effectiveness of a complicated grief
treatment in a small initial RCT, replicated results in
a larger sample, and a multicenter trial was recently
completed [31 ]. Furthermore, it should be inves-
tigated whether trial results generalize across
samples with lower education and more men, chil-
dren and adolescents, and people with non-Western
cultural backgrounds. Particular attention should be
directed to the independent replication of research
findings as this is rarely done, but it constitutes a key
criterion for the establishment of evidence-based
treatments [55]. In addition, dismantling studies
comparing the effects of different treatment com-
&
ponents (e.g., [7,53 ]) or effects of adding com-
ponents to a more comprehensive treatment (e.g.,
&
[8 ]) can provide information on which treatment
elements are most efficacious. Simultaneously,
new promising approaches should be tested (e.g.,
[56,57]), ideally against proven-effective treatments,
to benefit optimally from the creativity of research-
ers and clinicians.
How complicated grief treatments work can be
elucidated using two main methods. On the one
hand, the theoretical basis for complicated grief
treatment should be clarified further to improve
our understanding of how complicated grief can
best be targeted. For example, although studies have
shown that exposure to the loss can be highly
& &
effective in treating complicated grief [7,8 ,53 ],
evidence of the association between loss avoidance
and complicated grief is mixed. Surveys generally
show positive associations between both constructs
[39–42,44,48], but laboratory investigations have
shown conflicting results, sometimes yielding
positive associations between complicated grief
and attention for loss-related cues [58], and some-
times none [45,59]. On the other hand, mediators of
treatment effects should be examined, to ascertain
what processes explain treatment effects, so that
these mechanisms of change can be targeted
more effectively in complicated grief treatment.
www.co-psychiatry.com 289
Psychiatry, medicine and the behavioral sciences
Mediation analyses are surprisingly rare, with no
mediation analyses of complicated grief treatment
trials published to date, although treatment effects
on negative cognitions and avoidance processes
have been found to be associated with CBT treat-
ment effects on complicated grief [60].
It also needs to be investigated for whom com-
plicated grief treatment yields the best results, to
establish whether specific treatments need to be
developed for certain subpopulations. An older
meta-analysis showed that no variables other than
distress levels consistently moderate treatment
effects of grief interventions [25], and the effective-
ness of complicated grief treatments clearly illus-
trates this point. Few researchers have attempted to
further elucidate for whom complicated grief treat-
ment works best since this review. However, one
trial demonstrated that recently suicide-bereaved
persons with high suicide ideation showed larger
reductions in complicated grief symptoms in
response to CBT treatment than those with low
suicide ideation [61]. This seems to imply that no
specific treatments need to be developed for persons
with suicidal thoughts (as long as no acute suicidal
tendencies exists), but more research is indicated to
draw firm conclusions.
CONCLUSION
In summary, the diagnostic criteria as proposed in
ICD-11 and DSM 5, though critically discussed by
researchers and clinicians, will draw increased atten-
tion to the treatment of complicated grief. It
remains of utmost importance to avoid both over-
diagnosis and misdiagnosis of complicated grief.
Although recent research convincingly demon-
strates that psychological treatments (in particular
CBT) are effective in treating complicated grief,
there are still many remaining questions. This
review introduces a systematic research agenda to
answer these questions: we recommend conducting
both theoretically focused studies and clinical trials
in large, heterogeneous bereaved samples, to estab-
lish what treatment (components) are most effective
for whom and how these treatments work. This
would create a broad evidentiary base for treatments
that could inform clinicians and researchers and
optimally benefit bereaved persons in need of help.
In light of the encouraging evidence that has accu-
mulated during the period covered by this review,
this goal now seems more feasible than ever.
Acknowledgements
None.
Financial support and sponsorship
None.
290 www.co-psychiatry.com
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Conflicts of interest
There are no conflicts of interest.
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