Complicated Grief with Post-Traumatic Stress Disorder Addressed with Accelerated Resolution Therapy: Case Discussions (2023)

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Omega (Westport). Author manuscript; available in PMC 2022 Feb 5.

Published in final edited form as:

Omega (Westport). 2022 Jun; 85(2): 455–464.

Published online 2020 Aug 5. doi:10.1177/0030222820947241

PMCID: PMC8176788

NIHMSID: NIHMS1701889

Abstract

Complicated grief is a significant health concern for older adults, resulting in significant psychological and physical morbidity. Elements of post traumatic stress disorder (PTSD) are often present in individuals with complicated grief. Accelerated Resolution Therapy (ART) is a brief form of psychotherapy that utilizes the techniques of imaginal exposure, rescripting of events, and lateral eye movements that may be useful in complicated grief with PTSD symptoms. Two cases where ART was used for complicated grief with PTSD are presented. Both individuals had attempted to come to terms with their loss through traditional grief therapy with an inadequate response and substantial residual grief symptoms. These cases illustrate how ART can be used to address CG and PTSD and describe situations where it may be appropriate. Clinical and research implications are also discussed.

Keywords: grief, hospice, caregiver, complicated grief, psychological well-being

Introduction

Complicated grief is a significant health concern for older adults, affecting up to 25% of persons at least 55 years of age (). Complicated grief is associated with numerous psychological problems including loneliness, social isolation, anxiety, clinical depression,and cognitive impairment (; ). Loss of multiple close family and friends, increased likelihood that the deceased will be a spouse or partner, and financial burden associated with the loss, may lead to a higher incidence of complicated grief among older adults (; Newson et al., 2011).Complicated grief has negative health consequences, including altered sleep, activation of the neuroendocrine system, immune function disruption, inflammatory and prothrombotic activation, and hemodynamic changes (Buckley et al., 2012).

Co-occurring and somewhat overlapping symptom patterns of complicated grief and post-traumatic stress disorder (PTSD) suggest that PTSD treatments may also successfully treat complicated grief (Simon et al., 2007). Whereas PTSD is characterized typically by fear, horror, anger, guilt, or shame, combined with an anxious hyperarousal state and exaggerated reactivity, the experience of CG is marked primarily by yearning, loss, or emptiness (). This includes an intense longing for the deceased and distress over the loss of the relationship, which is not a central component of PTSD (). To further differentiate PTSD and CG, in PTSD after a loss, intrusive thoughts are fixated on the death event itself, leading individuals to avoid internal and external reminders of the death event in and of itself. On the other hand, in CG, individuals may experience intrusive and involuntary thoughts about diverse aspects of the relationship with the deceased, including positive content that the bereaved longs for, and avoidance is mostly limited to those stimuli that serve as reminders of the reality or permanence of the loss (). However, the cardinal symptom of emotional numbing since the time of the loss is shared by both CG and PTSD ().

Accelerated Resolution Therapy (ART) is a brief form of psychotherapy that utilizes the techniques of imaginal exposure, rescripting of events, and lateral eye movements (). Imaginal exposure focuses on visualizing the event from beginning to end while practicing specific relaxation techniques involving eye movements that are intended to engage the parasympathetic nervous system. Rescripting focuses on allowing the individual to incorporate more positive emotions into the memory of the event and imagine exerting personal control over the circumstances surrounding the traumatic event (Arntz, 2012). What differentiates ART from conventional cognitive-based interventions is the visualization of previous events and subsequent “mind-body” processing in as much detail as available. The rescripting of each event is in the Gestalt tradition (Edwards, 1989). However, unlike traditional psychotherapy techniques, the patient is directed to perform two tasks simultaneously (e.g. re-experiencing the traumatic grief experience and performing eye movements) which is believed to tax limited working memory capacity (). Importantly, this may force memory traces representing events, emotions, and sensations to compete for permanence (), as well as reduce the vividness and emotional intensity of the original traumatic material (Maxfield et al., 2008; ; ). We recently tested up to 5 sessions of ART in 54 older adults (60+) with complicated grief in a randomized wait-list controlled trial which demonstrated improvements in complicated grief, PTSD, and depression, using validated patient reported outcomes measures (Inventory of Complicated Grief, and PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and Center for Epidemiologic Studies Depression) when compared to a wait listed control group (Buck et al., 2020)(Clinical Trials.gov Identifier: NCT03484338; IRB # Pro00032358). The aims of this case discussion is to provide context to the use of ART as a potential treatment for co-occurring complicated grief and PTSD. Two cases that typified common experiences of the larger group were selected for inclusion in this paper, based on discussions with study staff and review of notes recorded during the ART sessions.

Case Descriptions

Consider the following two cases of individuals with documented high levels of complicated grief and PTSD symptoms:

Case 1: Gloria

Gloria is a 75-year-old Caucasian female whose husband of 51 years died while enrolled in hospice. After the death, she reported trouble experiencing positive feelings and had repeated, disturbing, and unwanted memories of her husband’s last weeks and death. She was lonely during the day and restless at night. She was seen by a clinical psychologist over a year after her husband’s death with severe symptoms of psychological trauma and complicated grief. She attended a grief support group for 3 months following her husband’s death but did not feel it was particularly helpful.

In the first ART session, the traumatic scene processed was the course of her husband’s illness, loss of her husband of 51 years, and the feeling of helplessness as he became physically weaker and required physical assistance she could not always provide. She stated she felt the “burden of his care,” but wanted to be there for him as he had always done for her. Her most intense memory was unsuccessfully trying to prevent him from falling in the shower and being on the floor with him in the shower unable to lift him. During the course of his illness, she continued to have hope of recovery until his most recent stroke. She was able to rescript the event to emphasize how much he loved her and appreciated her care, spontaneously recalling more tender and humorous moments during his care.

During the second ART session, her guilt and shame were addressed. She shared an episode where she lost patience with her husband while trying to prop him up in bed. She was able to rescript the memory with an emphasis on more of the intimacy they shared and his humor and appreciation for her care, while he could not move on his own. She also worked on feelings of guilt for leaving him alone at lunch or going to the gym. At his insistence, in order to have a break in caring for him, she went to lunch with a friend. Upon her return, Gloria found her husband soiled and in a chair where he had been for more than two hours. He refused to call her for help and remained in the chair so she could have a break. She was able to rescript the memory of this event, emphasizing his words of affirmation and past demonstrations of his care for her. Gloria was able to reframe the guilt and instead focus on how much they loved each other. She reported that since her first session, she rarely felt fearful and her sleep had improved.

During the third ART session, Gloria processed living without a loved one and memories of loneliness and loss of friendships and companions. She reported being able to recall more pleasant memories. She also reported that the repeated, disturbing dreams of the stressful experience had dissipated. In the fourth ART session, she worked through a typical day and her personal health. Gloria disclosed that she gained weight during her husband’s illness. This compounded her feelings of loss of identity. She reported feeling well without physiological distress or residual negative thoughts.

Case 2: Sue

Sue is a 65-year-old Caucasian female who experienced multiple, unexpected deaths. She was the primary caregiver for her mother who died unexpectedly in an intensive care unit (ICU)and was also the caregiver for her sister who died suddenly (to her) of metastatic cancer in an emergency room (ER) approximately a year prior to her mother’s death. She sought grief counseling after the death of her sister but her grief symptoms persisted despite eight months of individual therapy. She intentionally avoided memories, thoughts, or feelings related to the deaths, felt distant or cut off from people, and lost interest in activities she used to enjoy. She had no previous history of psychotherapy apart from her grief counseling.

During the first session, she processed the traumatic scene of the unexpected passing of her mother. Her mother’s death occurred in the ICU and this scene was treated (processed) using imaginal exposure and imagery rescripting (Kip et al., 2014). Physiological symptoms included tension headaches when thinking about the loss of her mother. Her primary feelings were loss, guilt, and anger. Her mother stated she would never go to a nursing home. While in the ICU, her mother’s health had improved and they were preparing for discharge. Knowing her mother did not want to be put in a nursing home, she attempted to prevent the discharge planner from discussing it. The discharge planner persisted to the point of raising his voice stating “you have to choose a nursing home!” At which point her mother suddenly died. Sue felt angry toward the discharge planner for “taking” her mother as well as guilty and angry toward herself for not “protecting her mother.” She stated that if she had protected her mother, she would have had additional time with her. She was able to process the intensity of the emotions and to rescript the memory of the event with an emphasis of the time she did have with her mother and the joy she got in providing care for her.

In the second ART session, the trauma that was being processed was the unexpected passing of her sister in the ER from cancer. Her sister moved to Florida and Sue expected to become her caregiver. She experienced the loss of her sister as an “ongoing loss,” due to periods of sickness and remission with cancer. The theme was the loss of a second close family relationship and loss of the expected caregiver role. With ART Sue was able to process the loss of her sister and concentrate on how she had been helpful to her sister.

During the third ART session, she processed new overwhelming news that her nephew is going to hospice due to a recent diagnosis of a brain tumor. This traumatic scene was compounded by the anniversary of the passing of her mother near the date of the session. Her primary feeling was fear which triggered a feeling of helplessness. She was asked to think back to when she had experienced a similar feeling of helplessness, a technique known as a “scene match”. During the “scene match” she recalled a similar feeling she had as a child when her parents would argue. Sue is a lay minister and after the second session she felt well enough to give a sermon for the first time since her mother’s death, but was unsure now how the news of her nephew’s decline would impact her ability to give the sermon.

In the fourth ART session, she worked through a typical day and the feeling of too much being on her plate, including stress around resuming some of her role as a lay minister. Although Sue seemed overwhelmed and reluctant, she was able to reimagine a more pleasant version of events with coaching from the therapist.

Comment

Both Gloria and Sue had attempted to come to terms with their loss through traditional grief therapy (group and individual) yet with an inadequate response and substantial residual grief symptoms. Both were able to process the distressing sensations that emerged during the imaginal exposure component of ART with the use of eye movements and experienced improvements in complicated grief and PTSD symptoms that were sustained for at least an eight week period.

These two cases illustrate grief reactions commonly seen in clinical practice, yet seldom addressed beyond traditional grief counseling and support groups. The close relationship and inter-dependence that Gloria shared with her husband likely made it more difficult to visualize and create a new life for herself after he died. The death of two immediate family members and personal guilt Sue felt connected to theses deaths likely prevented her from successfully resolving her grief and moving forward.

ART was used to help Gloria and Sue process their feelings and experiences surrounding the death of their immediate family member(s). The high distress in each case presented here appeared to be related to the experience and subsequent cognitive appraisal of the loss. With ART, the processing of emotions such as guilt, or re-experienced sensations associated with the recall of events such as the weight of a husband when the wife was unable to move him, seems to result in a natural or self-directed shift or change in the appraisal of the original events. Importantly, although the patient “sees” and “feels” differently about the original experiences after ART, there is no alteration of factual recall as to the historical details of the events. What is typically reported is an enhanced recall of details once the distressing sensations and thoughts are processed. For example, a different preferred outcome to the unexpected death was expressing one’s self toward the loved one to bring a sense of closure from being able to say goodbye where there had not been such a conversation and only regret.

ART represents a shift from managing the symptoms associated with complicated grief to treating the underlying psychological trauma. Improvements in trauma and grief seen in these two cases are consistent with the results seen in the larger group of participants (Buck et al., 2020). These case studies are meant to serve as examplars providing clinical context and in-depth narratives describing traumatic events during the illness and death process as well as how these events were processed using ART. While it is likely that previous interventions such as grief counseling, psychotherapy, and grief support group participation had already provided some benefit in terms of processing feelings and experiences related to their losses, individuals were referred to the study by the grief counselors who assessed them and determined that they were still experiencing high levels of CG that had not responded effectively to earlier intervention. In addition, patients met diagnostic criteria for complicated grief and PTSD at the beginning of the study, indicating that although they had likely benefited from previous interventions, it had not provided substantial benefit over the year or more following the death

Traumatic elements of each loss, appear to disrupt the grief process and while each of the two cases reported benefits from traditional grief counseling, they were only able to move forward in their process after addressing those distressing traumatic elements. As with other syndromes and conditions in older adults, non-pharmacological solutions, such as ART, ought to be tried first before resorting to medication because of the risks of polypharmacy and adverse drug reactions. ART appears to be a promising non-pharmacologic intervention for complicated grief. Further research is needed to test the effectiveness of ART in this setting and to compare ART to existing treatments described below.

To our knowledge, there has not been previous research on ART for treatment of CG. ART has previously been used to treat acute stress in soldiers who experienced a death during deployment in Afghanistan, with sustained improvements documented 1-year post incident measured at the end of deployment, although CG was not measured (). Other forms of psychotherapy may help complicated grief including Complicated Grief Treatment (CGT), (; ; Shear et al., 2014) a 16-week program that includes psychoeducation and dual-process applications for loss and restoration (Shear, 2015) CGT outperforms traditional grief focused psychotherapy in older adults(Shear et al., 2014) and has been adapted for group therapy with similar results.() Other interventions include family therapy,(Kissane et al., 2016; ) traditional group therapy,(; Kealy et al., 2017) and peer support(). However, interventions based on cognitive-behavioral techniques suffer from similar high resource use (clinician time and client burden), resulting in high cost and significant drop out rates.

There is still a need for interventions, which efficiently and cost-effectively treat complicated grief, as well as address any co-occurring PTSD. ART may offer some advantages over other therapies including fewer sessions, lower costs, and approach to addressing the most traumatic elements of the experience specifically. In this present application, ART can be seen as an adjunct to traditional services, as benefits were gained after a period of traditional care.

ART may be a possible treatment option when there is a high degree of interdependence between the deceased and the grieving person, multiple deaths within a relatively short period of time, someone feels responsible in some way for the death, or when there was some sort of physical or emotional trauma surrounding the death(s). Questions that remain include whether complicated grief is actually a traumatic response, and what are the circumstances in which ART may or may not be appropriate for complicated grief. as well as the ideal timing for ART following an unexpected loss. Future research should attempt to answer these questions. Rather than allowing patients to suffer for a year or more with complicated grief, studies should address optimal timing of interventions, as well as preventative strategies to minimize the psychological, social, and physical burden of complicated grief.

Acknowledgments

Funded by a grant from the NIH National Institute of Aging 1R21AG056584

Contributor Information

Cindy Tofthagen, Mayo Clinic.

Diego F. Hernandez, University of South Florida.

Tina M. Mason, University of South Florida.

Harleah G. Buck, University of South Florida.

Kevin E. Kip, University of South Florida.

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FAQs

Can you have PTSD and complicated grief? ›

Complicated grief is a significant health concern for older adults, resulting in significant psychological and physical morbidity. Elements of post traumatic stress disorder (PTSD) are often present in individuals with complicated grief.

Read The Full Story ›

What coping strategies work best for PTSD? ›

Positive ways of coping with PTSD:

Learn about trauma and PTSD.
Join a PTSD support group.
Practice relaxation techniques.
Pursue outdoor activities.
Confide in a person you trust.
Spend time with positive people.
Avoid alcohol and drugs.
Enjoy the peace of nature.

Mar 27, 2023

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What are the four phases of complicated grief treatment? ›

The intervention includes seven core procedures: (1) psychoeducation about CG and CGT; (2) self-assessment and self-regulation; (3) aspirational goals work; (4) rebuilding connections; (5) revisiting the story of the death; (6) revisiting the world changed by the loss; and (7) addressing memories and continuing bonds.

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What are the four types of complicated grief? ›

According to the ELNEC, there are four types of complicated grief, including chronic grief, delayed grief, exaggerated grief, and masked grief.

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What is the difference between traumatic grief and complicated grief? ›

When traumatic events lead to long-lasting effects on your emotions, cognition, and behavior, it is indicative of post-traumatic stress disorder (PTSD). But the loss of a loved one is also a traumatic event that causes similar disruptions. When they become prolonged, it is classified as complicated bereavement.

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What are the four symptoms of complicated grief? ›

Signs and symptoms of complicated grief may include:

Intense sorrow, pain and rumination over the loss of your loved one.
Focus on little else but your loved one's death.
Extreme focus on reminders of the loved one or excessive avoidance of reminders.
Intense and persistent longing or pining for the deceased.

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Dec 13, 2022

See Details ›

What is the most effective psychological treatment for PTSD? ›

(1) The CPG recommends individual trauma-focused psychotherapies, particularly Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitization and Reprocessing (EMDR) as the most effective treatments for PTSD.

What does a PTSD episode look like? ›

Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better.

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How long does it take to recover from post-traumatic stress disorder? ›

Some people recover within 6 months, while others have symptoms that last for 1 year or longer. People with PTSD often have co-occurring conditions, such as depression, substance use, or one or more anxiety disorders.

What are appropriate interventions for treating complicated grief? ›

Although it's important to get professional treatment for complicated grief, these strategies also may help you cope:

Stick to your treatment plan. ...
Practice stress management. ...
Take care of yourself. ...
Reach out to your faith community. ...
Socialize. ...
Plan ahead for special dates or anniversaries. ...
Learn new skills.

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Dec 13, 2022

What are the three types of complicated grief? ›

Three different types of complicated grief are posited: chronic grief, which is intense, prolonged, or both; delayed grief; and absent grief.

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What is the treatment for complicated grief? ›

There is help for people with prolonged grief disorder.

Prolonged Grief Disorder Therapy (PGDT) can make a big difference in their life. PGDT (previously called complicated grief therapy: CGT) was the first proven efficacious treatment for this condition and remains the approach most extensively tested.

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What is the toughest stage of grief? ›

Depression is usually the longest and most difficult stage of grief. Depression can be a long and difficult stage in the grieving process, but it's also when people feel their deepest sadness.

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What is an example of complicated grief? ›

As in acute grief, the hallmark of complicated grief is persistent, intense yearning, longing, and sadness; these symptoms are usually accompanied by insistent thoughts or images of the deceased and a sense of disbelief or an inability to accept the painful reality of the person's death.

Get More Info Here ›

Is complicated grief a disability? ›

However, for those with Prolonged Grief Disorder those feelings are not eased with time. For some, Prolonged Grief Disorder will be disabling and can make them eligible for Social Security Disability.

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What is the DSM-5 definition of complicated grief? ›

DSM-5 Category: Conditions for Further Study

Formerly known as complicated grief disorder, persistent complex bereavement disorder causes sufferers to feel extreme yearning for a deceased loved one, usually over a prolonged period.

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What are two characteristics of complicated or prolonged grief disorder? ›

Symptoms of prolonged grief disorder (APA, 2022) include: Identity disruption (such as feeling as though part of oneself has died). Marked sense of disbelief about the death. Avoidance of reminders that the person is dead.

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What are 6 symptoms of complicated grieving? ›

Symptoms of persistent and acute grief, which might include a yearning for the person who has died, feelings of loneliness, preoccupying thoughts about the person who has died. At least two of any symptoms of shock, anger, difficulty trusting other people, inability to accept death.

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What medication is used for prolonged grief disorder? ›

Naltrexone has the theoretical potential to be another form of treatment that can improve the mental health, physical health, and well-being of the bereaved with PGD.

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What is the success rate of PTSD therapy? ›

According to the National Center for PTSD, 53 of 100 patients who receive one of these three therapies will no longer have PTSD. With medication alone, 42 of 100 will achieve remission.

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What is the golden treatment for PTSD? ›

Exposure therapy has been thoroughly studied and referred to as the gold standard for PTSD patients, helping them process emotions and overcome their fears. The goal of exposure therapy is to actively confront the things that a person fears.

Is complicated grief a mental illness? ›

Despite not being a clinical disorder, complicated grief is recognized as a serious condition by mental health professionals.

What is the DSM 5 criteria for complicated grief? ›

DSM V PGD requires the occurrence of a persistent and pervasive grief response characterized by persistent longing or yearning and/or preoccupation with the deceased accompanied by at least 3 of 8 additional symptoms that include disbelief, intense emotional pain, feeling of identity confusion, avoidance of reminders ...

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Can complicated grief cause memory loss? ›

Additionally, in the instance of complicated grief, an individual can suffer from further issues, such as memory complications. A study from Harvard University found that people who suffer from this long-term grief often have trouble recalling past memories that don't involve their lost partner.

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