Psychological interventions for grief: a systematic review (2023)

Grief is a natural reaction to loss. Time really does heal, and as it passes, most bereaved people gradually come to terms with their grief.

However, a significant minority do not and remain very distressed, experiencing abnormally persistent grief over an extended period. For some, this presents as depression and/or post-traumatic stress symptoms, but others (1 in 10: Lundorff et al, 2017) experience a very particular kind of loss-related distress: persistent yearning for and preoccupation with the dead person, intense emotional pain and major problems in successfully getting on with everyday life. This syndrome of ‘Prolonged Grief Disorder’ is now included as a diagnosis in ICD-11 (with a minimum duration of 6 months post loss). Prolonged, ‘pathological’ or ‘complicated’ grief, as many of us know it, is bad both for our longer-term health and quality of life (see this 2015 elf blog by Olivia Maynard: Are changes in routine health behaviours the missing link between bereavement and poor physical and mental health?).

There have been considerably more randomised controlled trials published since previous systematic reviews of psychological interventions for grief (Currier et al, 2008; Wittouck et al, 2011). These newer trials have also used a clearer definition of prolonged grief when deciding both who to include in studies, and how to judge success of outcomes.

A newmeta-analysis by Maja Johannsen and her colleagues from Aarhus, Denmark, evaluates the efficacy of psychological interventions for grief in bereaved adults. It also explores possible moderating influences (a range of population, intervention and study characteristics that might explain variation in outcomes).

Psychological interventions for grief: a systematic review (2)

Prolonged Grief Disorder affects 1 in 10 of those bereaved and is bad for our health and quality of life.

(Video) Complicated Grief Impact and Interventions


A systematic literature search was conducted by two reviewers who independently searched electronic databases, reviewed and selected eligible studies, evaluated their methodological quality, carried out a meta-analysis and explored for publication bias.

Inclusion criteria

  • Studies of adults ≥ 18 years at time of loss
  • Bereavement defined as: ‘loss of live-born person’ excluding pets, jobs, stillbirth
  • Included quantitative measure of prolonged grief symptoms
  • Reported data from a psychological intervention (cognitive-behavioural, emotional-supportive and or psychoeducation delivered by health professionals)
  • Only randomised controlled trials (RCTs).

Exclusion criteria

  • Studies of bereaved children and adolescents
  • Intervention with main focus on physical aspects (e.g. acupuncture, relaxation, massage)
  • Complementary and alternative interventions
  • Interventions aimed at professionals only
  • Reported only proxy measure of grief as outcome (e.g. other types of complicated bereavement reactions such as post-traumatic stress or depression symptoms)
  • Qualitative studies
  • Grey literature.

Quality criteria

  • An adapted version of the JADAD quality assessment tool for RCTs was used
  • Scored on 0-9 point scale with 7 items
    1. randomisation, (0-2 points)
    2. blinding, (0-2 points)
    3. dropouts and withdrawals, (0-1 point)
    4. a priori primary outcome and (0-1 point)
    5. power calculation, (0-1 point)
    6. inclusion based on high level of primary outcome (0-1 point)
    7. used one of 3 valid measures of complicated grief: the Inventory of Complicated Grief (ICG) (Prigerson et al, 1995) the revised version (ICG-R) (Prigerson & Jacobs, 2001) or the Prolonged Grief Instrument (PG-13) (Prigerson et al, 2009) (0-1 point)

Meta-analytic strategy

  • Effect sizes (ESs) were calculated for each study
  • An overall pooled ES was calculated for the efficacy of psychological interventions on grief symptoms at post-intervention (first assessment after) and follow-up (longest time point). Hedge’s g (Hedges & Olkin, 1985) was chosen as the standard ES parameter
  • ESs of 0.20, 0.50 and 0.80 were considered small, medium and large (Cohen, 1988)
  • Moderator analyses were planned to explore possible sources of variation in outcomes between studies.


  • 32 studies were identified, including 4,760 bereaved adults of whom 73% were women. 31 randomised controlled trials (RCTs) were included in the meta-analysis (data needed was unavailable for 1)
  • 53% measured grief with the ICG-(R) or PG-13, with the others using 10 different measures
  • 88% used a grief specific intervention, 59% provided individual therapy and 78% face-to-face with a mean of 10 sessions (range 1-20)
  • The mean quality score was 5 (the range was 1-9)
  • Statistically significant pooled effects of psychological intervention on grief symptoms were found for both:
    • Post-intervention (Hedges’s g = 0.41, p > .001, K = 31)
    • Follow-up (g = 0.45, p > .001, K = 18)
  • The effect was smaller, but still significant, at post-intervention when adjusting for possible publication bias (g = 0.31)
  • Compared with the remaining studies, larger post-intervention effect sizes were found for studies with:
    • Individually delivered interventions (Beta = 49, p < .001),
    • The ICG-(R)/PG-13 questionnaire as the grief instrument (Beta = 0.46, p < .001),
    • Participants who were ≥6 months post-loss (Beta = 0.58, p < .001),
    • Participants included based on high baseline symptom levels (Beta = 0.40, p = .002) and
    • Higher study quality (Beta = 0.06, p = .013).


The authors conclude that:

Given the recent introduction of Prolonged Grief Disorder in the ICD-11, the results of the present meta-analysis are timely and of clinical relevance.


Based on our results, psychological intervention appears efficacious for alleviating grief symptoms in bereaved adults, with several study characteristics as possible moderators of the effect.

(Video) Our Mental Wellness: Coping with grief after a bereavement

Psychological interventions for grief: a systematic review (4)

With Prolonged Grief Disorder now included in ICD-11 there may be increased awareness of the need to recognise and help people who have complicated grief.

Strengths and limitations

Strengths of the review

  • Timely and rigorously conducted update on previous reviews
  • Comprehensive investigation of possible moderators to explain variation in outcomes.


  • Heterogeneous studies (both in methods and quality). Surprisingly higher quality studies predicted larger effects. In my opinion, study quality is a major limiting factor
  • Evidence of publication bias
  • Limited clinical value of the results: effect sizes were small, and it isn’t known what a clinically meaningful change would be for any of the self-report grief measures used
  • This review tells us little about what is likely to work in terms of a psychological intervention for grief and for who. As the authors state:

results should be interpreted in the light of the considerable diversity within the current field of psychological grief management.

Implications for practice

As someone who has both personally experienced persistent grief after the death of a parent and cared for many people with complicated grief, I recognise it as something which is frequently misunderstood and underestimated. ‘Grief is normal- you’ll get over it,’ just doesn’t work for some. Those who experience normal bereavement don’t need therapy. They need to know grief will pass with time. However, those who are experiencing complicated grief do need it.

(Video) Evolving Models of Grief and Grief Counselling

As a professional, I found Shear’s ‘Complicated Grief Treatment’, which combines both talking about and coming to terms with the loss as well as re-engaging in every life, a useful clinical approach, and there is good evidence for it (Shear et al, 2005). However, I’d be interested to know how many psychological therapy services offer specific grief therapies (not simply referral to a self-help group)?

This review shows that waiting 6 months before offering specific grief therapy is wise. But what about when a loss is complicated by PTSD and/or has resulted in depression, neither of which were addressed in this review? Although depression can be diagnosed too early and easily (Dowrick & Frances 2013) the rigid delay before even seeing someone after a bereavement, operated by some psychological therapy services, seems unacceptable.

It’s time to pay more attention to the suffering caused by prolonged grief both in research and clinical practice.

Psychological interventions for grief: a systematic review (6)

Waiting for6 months before specific grief therapy is wise, but depression and/or PTSD may require earlier intervention.

Statement of interests

Linda Gask does nothave any conflicts of interest other than being a non-executive director of a social enterprise (Six Degrees in Salford, Greater Manchester) that provides psychological therapy via Improving Access to Psychological Therapies.


Primary paper

Johannsen M, Damholdt MF, Zachariae R., Lundorff, M et al (2019) Psychological interventions for grief in adults: a systematic review and meta-analysis of randomized controlled trials.Journal of affective disorders. 253: 69-86

(Video) The Science & Process of Healing from Grief | Huberman Lab Podcast #74

Other references

Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences. Lawrence Erlbaum, Hillsdale, N.J.

Currier JM, Neimeyer RA, & Berman JS (2008) The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review.Psychological bulletin,134(5), 648.

Dowrick C & Frances A (2013) Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit.bmj,347, f7140.

Hedges LV & Olkin I (2014)Statistical methods for meta-analysis. Academic Press

Lundorff M, Holmgren H, Zachariae R et al. (2017) Prevalence of prolonged grief disorder in adult bereavement: A systematic review and meta-analysis.Journal of Affective Disorders,212, 138-149.

Prigerson HG, Horowitz MJ et al. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11.PLoS medicine,6(8), e1000121.

Prigerson HG & Jacobs SC (2001) Diagnostic criteria for traumatic grief: A rationale, consensus criteria, and preliminary empirical test.Handbook of bereavement research: Consequences, coping, and care, 613-645.

Prigerson HG, Maciejewski PK, Reynolds III CF et al. (1995) Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss.Psychiatry research,59(1-2), 65-79.

(Video) Complicated Grief after Suicide Bereavement and Other Causes of Death: Results from the HEAL Study

Maynard O. (2015) Are changes in routine health behaviours the missing link between bereavement and poor physical and mental health? The Mental Elf 6 July 2015

Shear K, Frank E, Houck PR et al. (2005) Treatment of complicated grief: a randomized controlled trial.Jama,293(21), 2601-2608.

Wittouck C, Van Autreve S, De Jaegere E et al. (2011) The prevention and treatment of complicated grief: a meta-analysis.Clinical Psychology Review,31(1), 69-78.

Photo credits


What theories are used in grief counseling? ›

In this article, we explore three of these models: Freud's Model of Bereavement. Kubler-Ross Grief Cycle. Bowlby's Attachment Theory.

What is the difference between grief and bereavement? ›

Everyone will experience loss at some point in life. However, there is a difference between grief and bereavement. Grief describes the response to any type of loss. Bereavement is grief that involves the death of a loved one.

How are the stressors dealt with according to the dual process model of grief? ›

This model identifies two types of stressors, loss- and restoration-oriented, and a dynamic, regulatory coping process of oscillation, whereby the grieving individual at times confronts, at other times avoids, the different tasks of grieving.

What can unresolved grief cause? ›

Young children may show unresolved grief by developing behaviour problems or expressing fears about being alone, especially at night. People with unresolved grief who do not seek treatment are more likely to develop complications such as depression as a result of grieving.

What are some interventions for grief? ›

Some of the grief therapy interventions that are available include:
  • Cognitive behavioral therapy (CBT) ...
  • Acceptance and commitment therapy (ACT) ...
  • Traumatic grief therapy. ...
  • Complicated grief therapy (CGT) ...
  • Group Therapy. ...
  • Art therapy. ...
  • Play therapy.
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What is the 3 factor grief counseling model? ›

3 Techniques used in Grief Counseling

Three of the biggest things a good grief counselor can do for their client are to: Let them talk about the deceased; ask them about the person, and allow them to speak about their lost loved one in a safe space.

How long is too long grieving? ›

There is no timeline for how long grief lasts, or how you should feel after a particular time. After 12 months it may still feel as if everything happened yesterday, or it may feel like it all happened a lifetime ago. These are some of the feelings you might have when you are coping with grief longer-term.

How long does grief brain last? ›

The fog of grief is emotional, mental, and physical and can take time to unravel and release. In most cases, your memory loss and inability to concentrate should lift within a few months and aren't permanent. In some cases, it may take longer.

What is dysfunctional grieving? ›

Dysfunctional grieving represents a failure to follow the predictable course of normal grieving to resolution (Lindemann, 1944). When the process deviates from the norm, the individual becomes overwhelmed and resorts to maladaptive coping.

What is the most important and most difficult task a grieving person must accomplish? ›

You don't need to have answers or give advice or say and do all the right things. The most important thing you can do for a grieving person is to simply be there. It's your support and caring presence that will help your loved one cope with the pain and gradually begin to heal.

What is the most recent grief theory? ›

Adaptive Grief is another newer model. It was proposed by grief researchers Kenneth Doka and Terry Martin in the book Grieving Beyond Gender. Their model reflects that grief is a complex process that's unique to the individual and has many variables — including personality and a person's culture.

What is tonkins model of grief? ›

Tonkin's theory of grief suggests that over time, your grief will stay much the same, but your life will begin to grow around it. You will have new experiences, meet new people, and begin to find moments of enjoyment. Slowly, these moments may grow more frequent and the outer circle will grow a little bigger.

How many grief theories are there? ›

In the past several decades, three diverging grief theories have offered alternate explanations for how a bereaved individual processes and deals with grief. While no single grief model applies to all grievers, practical application of these theories can help a bereaved individual explore the grief process.

Which is the most recent grief theory? ›

Adaptive Grief is another newer model. It was proposed by grief researchers Kenneth Doka and Terry Martin in the book Grieving Beyond Gender. Their model reflects that grief is a complex process that's unique to the individual and has many variables — including personality and a person's culture.

What are three different types of grief models? ›

Models of Grief
  • Denial.
  • Anger.
  • Bargaining.
  • Depression.
  • Acceptance.
5 Nov 2019

What is Freud's grief work theory? ›

Freud believed that the mourner has to work through the grief (grief work hypothesis) by carefully reviewing thoughts and memories of the deceased (hypercathexis). He maintained that although the process of working through causes intense distress, it is necessary in order to achieve detachment from the loved one.


1. Psychology Lecture: Coping with Grief and Loss by Sheila Schindler
2. Psychosocial Elements of Terminal Illness, Palliative Care and Grief | Case Management Certification
(Doc Snipes)
3. Continuing Bonds in Bereavement: Insights from Research and Grief Therapy Practice - Edith Steffen
(Grief: A Study of Human Emotional Experience)
4. Treatment for Grief and Complicated Grief
(Gladney University)
5. Treating Grief Through a Narrative Lens: Practical Bereavement Therapy Interventions
(Canadian Association of Social Workers)
6. Laurie Pearlman - Treating Adult Traumatic Bereavement
(APA Division 56 - Trauma Psychology)
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