Paul A. Boelen et al.

16 Prolonged grief disorder

Cognitive–behavioral theory and
therapy
Paul A. Boelen, Marcel van den Hout, and
Jan van den Bout

Introduction
For a minority of people, the death of a loved one precipitates the development
of prolonged grief disorder (PGD), or complicated grief (CG) as it has also been
named (e.g., Prigerson et al., 2009). PGD has been defined as a clinical condition
that encompasses specific grief reactions (including separation distress, difficul-
ties accepting the loss, and moving on without the lost person) that cause signifi-
cant distress and disability at least 6 months after the death occurred. Symptoms
of PGD are distinct from normal grief, bereavement-related depression, posttrau-
matic stress disorder (PTSD), and other anxiety symptoms and syndromes, and, if
left untreated, associated with significant impairments in health and quality of life
(Prigerson et al., 2009; see also Chapter 7 in this volume).
Parallel to the growing recognition of PGD as a distinct disorder, increasing
attention is being given to its treatment, with the most well-tested and effective
recent therapies being based in cognitive–behavioral therapy (CBT). For instance,
Shear, Frank, Houck, and Reynolds (2005) found “complicated grief treatment”
– a 16-session treatment containing elements CBT such as imaginal exercises to
revisit the death (exposure) and working toward achievement of personal goals
– to be effective in reducing PGD. Wagner, Knaevelsrud, and Maercker (2006)
found Internet-based CBT, including elements of confronting the loss, cognitive
restructuring, and social sharing, to be effective in reducing PGD and concomitant
depressive and anxious symptoms. We examined the effectiveness of a 12-session
CBT for PGD, based on a cognitive–behavioral conceptualization of the condition
(Boelen, de Keijser, van den Hout, & van den Bout, 2007). Compared with sup-
portive counseling, CBT was considerably more effective in ameliorating PGD
symptoms.
The present chapter addresses the theory and treatment of PGD from the per-
spective of cognitive–behavioral theorizing, with a focus on our own theoretical
approach (Boelen, van den Hout, & van den Bout, 2006). Notably, this approach
bears resemblance to other recent theoretical approaches to PGD (Shear, Boelen,
& Neimeyer, 2011). Specifically, this chapter will (1) introduce a theoretical basis
of CBT for PGD, (2) describe key interventions included in this approach, and (3)
review research on its theoretical underpinnings and effectiveness.

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Theoretical basis of CBT for PGD

One puzzling aspect of PGD is that, although people with PGD are so bound
up with the loss that they have difficulty functioning, the loss continues to feel
unreal. That is, for people suffering PGD, the disbelief, pangs of pain, and separa-
tion distress that normally occur intensely early after the death exacerbate rather
than gradually fade. We formulated a cognitive–behavioral model that attempts
to explain why, in some individuals, acute grief reactions persist and exacerbate
(Boelen, van den Hout, & van den Bout, 2006). This model proposes that three
interrelated processes account for this: (1) insufficient elaboration and integra-
tion of the loss within autobiographical memory; (2) negative thinking; and (3)
anxious and depressive avoidance behaviors.
This model draws heavily on general cognitive–behavioral theorizing (Beck,
1976) and multirepresentational models of psychopathology, in which various
forms of mental representation (cognitions, schemas, image representations,
distributed networks) and behavioral and cognitive responses are combined to
explain psychopathology (Dalgleish, 2004; Teasdale, 1999). This model is par-
ticularly inspired by Ehlers and Clark’s (2000) cognitive model of PTSD. Next,
these three processes will be described in more detail.

Insufficient elaboration and integration of the loss

Prototypically, in uncomplicated grief, explicit (i.e., consciously accessible)
knowledge that the separation is irreversible gradually gets integrated with exist-
ing knowledge about the self and the lost person, which is part of the autobio-
graphical memory base. This process is fostered by actively elaborating on the
implications of the loss for the self in the past, present, and future, as well as
by confronting external changes caused by the loss. Thus, through a process of
(active) elaboration, explicit knowledge about the loss gradually gets connected
with implicit memory knowledge about the self and the relation with the lost
person. The effect of this process is that the loss becomes part of the life story of
the mourner and gradually becomes a less disruptive, more normalized (albeit still
painful) event (cf. Ehlers & Clark, 2000).
Our CBT model postulates that, in PGD, this process of elaboration and integra-
tion is stalled or incomplete. This has several effects. A first effect is that, because
memory knowledge about the separation is disconnected from other memory
knowledge, the death continues to be a very shocking, unbelievable event. At the
same time, because the loss is so emotional and consequential, all kinds of stimuli
easily elicit memories, thoughts, and feelings that are associated with the death
such that – eventually – everything is a reminder of it. Stated differently, the lack
of connectivity between memories of the loss and other knowledge is assumed to
cause these memories to continue to intrude into awareness, causing PTSD-like
symptoms of intrusions, and a continued sense of shock, as if the loss happened
very recently rather than months or years ago (cf. Conway & Pleydell-Pearce,
2000).

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 Prolonged grief disorder 223
A second effect is that too little adjustment of knowledge about the self takes
place, as a result of which the person is left with a reduced sense of clarity about
the self. Integration of the reality of the loss with knowledge about the self is a
prerequisite for mourners to be able to redefine who they are without the lost
person. To the extent that this integration fails, a mismatch exists between the
external reality (absence of loved one) and self-knowledge (partially defined in
terms of lost person). This, in turn, can lead to an impaired sense of self-clarity:
a situation in which roles, goals, personal attributes, and other aspects of the self
that the lost person co-defined are temporarily unclear, fragmented, and unstable
(Campbell et al., 1996). This reduced self-clarity probably contributes to the wish
to revert back to the pre-loss period, difficulties in accepting the loss, isolation,
and a sense that life lacks meaning – symptoms that are all hallmark features of
PGD (Boelen, Keijsers, & van den Hout, 2012).
The third effect is that no adjustment of the “relationship representation” takes
place, so separation distress persists. Individuals form mental representations
of relationship with close others as part of autobiographical memory (Bowlby,
1980; Mikulincer, 2006). These contain information about emotional (anxiety,
despair) and behavioral responses (crying, searching) that are activated when the
relationship is threatened and that serve to maintain proximity and felt security.
When a loved one dies, a process normally unfolds in which the fact that the loss
is irreversible connects with the relationship representation. This coincides with
a gradual reduction of such reactions of separation distress. To the extent that
there is a lack of integration of the loss with the relationship representation, the
absence of the lost person will continue to generate symptoms of separation dis-
tress that are central to PGD. This notion links up with Shear and Shair’s (2005)
biobehavioral model of bereavement that also proposes that “symptoms of acute
grief . . . usually resolve following revision of the internalized representation of
the deceased to incorporate the reality of the death. Failure to accomplish this
integration results in the syndrome of complicated grief’ (p. 253).
In sum, the notion that, in persons suffering from PGD, information about the
separation is insufficiently connected with memory knowledge about the self and
the lost person helps to explain how the loss can be experienced in different ways:
how it can be thought about constantly but still feel shocking and unreal, how
mourners can say that the loss has changed them, but still feel left with a reduced
self-clarity, and how they rationally know that their loss is permanent but, at a less
conscious level, continue to experience the separation as reversible.

Persistent negative thinking

As a second process, the CBT conceptualization proposes that, unlike people
who recover from loss, individuals with PGD have rigid negative cognitions and
assumptions that contribute to the maintenance and exacerbation of their acute
grief symptoms (Boelen, van den Hout, & van den Bout, 2006). Two categories of
cognitions are particularly important. The first includes negative global cognitions
about the self (“I am a worthless person without my husband”), life (“Life has

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224 Paul A. Boelen et al.
no meaning any more”), and the future (“I will certainly never find joy again”).
These global negative views may develop when the loss shatters pre-existing
positive views. For instance, the loss of a child may lead to negative views of
self and life, when this event is strongly at odds with pre-existing positive views
and the person is unable to maintain positive views taking into account the loss
event. Such beliefs can also arise when the loss reactivates pre-existing negative
assumptions. The death of a loving partner may reactivate negative views that one
is a worthless person. The importance of global negative views of self and life in
emotional problems following loss accords with earlier theories of coping with
loss (Janoff-Bulman, 1992) and trauma (Foa & Rothbaum, 1998; see also Park,
2010). These theories have emphasized that recovery from such events hinges on
a person’s ability to maintain positive views of self and life following such events.
The second category includes catastrophic misinterpretations of one’s own
reactions to the loss. Bereaved people have to manage painful emotions, thoughts,
and memories. Acceptance of these responses fosters emotional processing.
Problems arise when people interpret these responses in a catastrophic fashion.
Mourners may label the intensity of their sadness as signaling loss of control,
view their numbness as announcing depression, and interpret vivid intrusions
as reflecting insanity. Such misinterpretations are assumed to fuel distress and
avoidance and to prevent the person from reviewing and adjusting to the loss’s
implications. Trauma research has shown that catastrophic interpretations of ini-
tial posttraumatic stress symptoms (e.g., “If I think back to this accident, I will go
out of my mind”) contribute to the development of chronic PTSD (Mayou, Ehlers,
& Bryant, 2002). After bereavement, similar misinterpretation are assumed to
contribute to acute grief reactions becoming chronic.

Anxious and depressive avoidance

Anxious avoidance refers to avoidance of confrontation with the reality, impli-
cations, and pain of the loss, driven by the fear that this confrontation will be
intolerable and unbearable. The importance of avoidance behaviors in maintain-
ing grief draws from early behaviorist accounts in which pathological grief was
essentially seen as a phobia for normal grief reactions (Ramsay, 1977). Anxious
avoidance resembles the concept of experiential avoidance, referring to attempts
to alter the frequency, duration, or form of negatively evaluated private events
such as thoughts, feelings, and memories (e.g., Hayes, Wilson, Gifford, Follette,
& Strohsahl, 1996). It is the opposite of experiential acceptance, reflecting the
willingness to endure unwanted private events without judgment and defense.
Anxious avoidance can manifest itself in situational avoidance of places, pictures,
and people associated with the loss. It may also take the form of cognitive avoid-
ance behaviors, including the suppression of unwanted thoughts and memories, or
rumination about events surrounding the death (e.g., “Why did the loss occur?,”
“How could it have been prevented?”) as a means to keep thoughts and memories
that are even more painful to think about out of awareness.
Anxious avoidance can be distinguished from depressive avoidance, which
refers to withdrawal from social, occupational, and recreational activities that

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 Prolonged grief disorder 225
could be rewarding and provide a continued sense of self. The concept draws from
early behavioral models of depression that implicated decreases in non-depres-
sive, rewarding behaviors as a key maintaining factor in clinical depression (e.g.,
Jacobson, Martell, & Dimidjian, 2001). After bereavement, depressive avoidance
can occur when the loss interrupts access to reinforcers for healthy behavior. As
Ramsay (1977) put it, “A widow whose reinforcers consisted of doing everything
with and for her husband suddenly finds herself left with no positive reinforcers
when he dies” (p. 133). In addition, it can occur when mourners lack the skills
needed to achieve valued goals in the absence of the lost person, or when they
think that engaging in activities without the lost person is disrespectful to him or
her. Negative cognitions are assumed to be important in depressive avoidance as
well, especially those concerning the effects of engaging in potentially helpful
behaviors (e.g., “Meeting friends will not make me feel better”) and one’s abilities
to do so (e.g., “I am unable to take up new responsibilities”). The reduction of
interest and competence in autonomous functioning, implicated in the concept of
depressive avoidance, also results from inhibition of the biobehavioral explora-
tory system circuitry that occurs with the activation of attachment responses fol-
lowing loss (Elliot & Reis, 2003; Shear et al., 2011).
Both forms of avoidance are detrimental. For instance, anxious avoidance is
detrimental because it causes distress and interferes with the elaboration and inte-
gration of the irreversibility of the loss and the implications thereof. Depressive
avoidance is detrimental because it interferes with the experience of positive emo-
tions and maintains negative views of the self, life, and future.

Interaction between, and the mediating role of, the three processes
The three processes are assumed not only to directly contribute to symptoms of
PGD, but also to influence each other. For instance, elaboration of the loss, and
subsequent integration of the reality of the loss with memory knowledge about
the self and the lost relationship, is likely to be blocked when reviewing the con-
sequences of the loss brings to mind negative thoughts about the self, life, and the
future. Likewise, a tendency to engage in anxious avoidance is likely to prevent
such integration. Negative cognitions and avoidance behaviors also have a mutual
impact. For instance, negative cognitions about the self and life are likely to main-
tain a depressive cycle of withdrawal and inactivity. Catastrophic misinterpreta-
tions of grief reactions can contribute to anxious avoidance behaviors, which, in
turn, prevent correction of such misinterpretations.
Important also is that the three processes are assumed to mediate the impact
of various established risk factors for poor bereavement outcome. These include
personality characteristics of the bereaved individual, such as neuroticism and
insecure attachment style; features characterizing the loss, such as who died
and the mode of death; and events and circumstances occurring in the aftermath
(e.g., perceived social responses). Put another way, it is proposed that the three
processes are intermediate mechanisms that explain why, for instance, people
who are insecurely attached have an elevated chance of developing PGD (cf.
Wijngaards-de Meij et al., 2007). This is so because these people are likely have

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226 Paul A. Boelen et al.
more difficulties in accepting and integrating the reality of the loss (Process 1),
maintaining a positive view of self (Process 2), and engaging in helpful coping
behaviors (Process 3), as a result of which they have a greater chance of develop-
ing PGD. The notion of mediation is important because it sheds light on change-
able mechanisms (e.g., negative cognitions) that can be targeted in treatment, to
curb the effect of more static, less easily changeable risk factors (e.g., personality
features) on the development and maintenance of PGD.

Cognitive–behavioral treatment
The aim of CBT for PGD is to alleviate persisting acute grief symptoms and to
help the person to achieve valued goals. To accomplish this, (1) the loss needs to
be integrated with existing knowledge, (2) unhelpful thinking patterns need to
be identified and altered, and (3) unhelpful avoidance strategies need to replaced
by more helpful ones. Different conventional CBT interventions can be used to
achieve these aims. Examples of interventions are described below.

Promoting elaboration and integration of the loss

A key intervention to directly target the lack of integration is exposure. During
exposure, the person is encouraged to gradually confront the painful reality of the
loss and to elaborate upon its implications. Several means can be used to achieve
this aim. The person suffering from PGD can be asked to tell or write a detailed
story about the events surrounding the death. This can be followed up by repeated
reliving of the most painful aspects (or so-called hot spots) of the story. Such
exposure is similar to revisiting the death, an intervention central to Shear’s com-
plicated grief treatment (Shear et al., 2005, 2011). This exercise uses a procedure
similar to prolonged exposure in the treatment of PTSD (Foa & Rothbaum, 1998)
and includes a reliving and subsequent further discussion of the most troubling
moments surrounding the death.
Imaginal exposure or reliving can be complemented with writing assignments.
People suffering from PGD can be instructed to write a detailed account of the
moments surrounding the loss: a procedure that is central to Internet-based CBT
for PGD (Wagner et al., 2006; Chapter 17 in this volume). In our own experience,
it is particularly useful to encourage them to write a letter to the lost person, care-
fully reviewing what is missed most now that he or she is dead. Within-session
exposure can also be complemented with exposure to situations or stimuli outside
therapy. Visiting the hospital where the loved one died or visiting places the lost
person always used to visit may help people with PGD to accept that the loss
occurred and to put it in the past.
As applied in this manner, exposure is not used to promote emotional habitu-
ation to painful memories and emotions. Instead, it is used to identify the most
painful memories that need to be confronted and worked through in treatment and
the most important guilty, angry, shameful, and frightening beliefs that need to be
re-evaluated. It is also used to encourage the person with PGD to fully connect

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 Prolonged grief disorder 227
with the reality of the loss and to lessen the disbelief. In addition, it is meant to
help the person to experience that experiential avoidance of the loss is fruitless,
that he or she has the strength to confront the loss, and that doing so lessens the
pain and fosters adjustment.

Changing maladaptive cognitions and assumptions

Cognitive restructuring aims to alleviate emotional suffering by (1) identifying
(maladaptive) cognitions that underlie a person’s suffering in particular situations
and circumstances; (2) examining the validity and utility of these cognitions; and
(3) reformulating these cognitions incorporating information gathered in step 2
into cognitions that are associated with less suffering and facilitate constructive
action. Cognitive restructuring focuses on the idiosyncratic meanings of the loss
and its sequelae, with a particular focus on global negative views of the self, life,
and the future and catastrophic misinterpretation of grief reactions. In identify-
ing maladaptive cognitions, it is important to search for relevant cognitions. Not
every negative cognition can be changed or should be changed. Instead, the thera-
pist should look for those cognitions that are central to the problems of the person,
that interfere with the achievement of valued goals, and that are falsifiable. For
example, it is hard to dispute the cognition “Life is meaningless” but easier to
discuss the validity of the cognition “Life has no meaning now, and I probably
won’t find meaning in life in the future.”
When relevant cognitions are identified, both verbal and behavioral techniques
can be used to change these cognitions. An example of the former one is using
Socratic questioning to investigate the validity (“How do I know that what I think
is true?,” “What evidence is there in favor and against this thought?”) and utility
(“What will happen if I continue thinking this way?,” “What is the worst thing
that can happen if what I think it true?”) of a particular cognition.
Behavioral techniques include behavioral experiments. These are specified
actions/assignments that patients undertake in order to test specific maladaptive
cognitions and catastrophic misinterpretations as well as the validity of alterna-
tive, more positive predictions (cf. Bennett-Levy et al., 2004). They are particu-
larly suitable for testing specific negative predictions (with an If . . . , then . . .
format) that lead to negative feelings and block constructive action. For instance,
a cognition such as “If I think over the implications of this loss, I will get so sad
that that I would go crazy” can be tested by encouraging the person to gradu-
ally review the consequences of the loss within the safe context of the therapy. A
negative cognitions such as “If I share my feelings about this loss, nobody will be
really supportive” could be tested by encouraging the person to set up a meeting
with a friend to talk about how he or she has felt recently.
Writing assignments can be used to complement within-session cognitive
restructuring. For instance, people suffering from PGD can be instructed to write
a supporting letter to an imaginary friend who has the exact same problems, with
an emphasis on trying to help this friend to re-evaluate maladaptive cognitions
about the loss (see Wagner et al., 2006; Chapter 17 in this volume).

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228 Paul A. Boelen et al.

Reducing anxious and depressive avoidance

In targeting anxious avoidance, cognitive restructuring is used to identify and
discuss the prediction that underlies the avoidance of particular loss-related
stimuli (e.g., “If I looked at a photo of my deceased wife, the pain would be so
intense that I’d turn into an emotional wreck”). Then, behavioral experiments, as
described in the previous section, can be used to test the validity of the prediction
further (Bennett-Levy et al., 2004). This often means that people are encouraged
to confront the avoided stimuli, in order to experience that doing so alleviates
rather than attenuates the suffering. Behavioral experiments resemble exposure
interventions. Notably, though, behavioral experiments are explicitly meant to
change specific assumptions, whereas exposure interventions can have various
aims (including identification of “hot spot” memories and maladaptive cogni-
tions, and encouraging elaboration of the loss).
Anxious avoidance may coincide with particular strategies developed to
minimize distress – strategies that are reminiscent of “safety behaviors” in
anxiety disorders. For instance, people suffering PGD may engage in compulsive
proximity-seeking behavior (e.g., visiting the graveyard twice a day), or rumina-
tive thinking about why the loss occurred, in order to minimize confrontation with
the pain associated with the irreversibility of the death. Response prevention can
be used to gradually eliminate such behavior. The procedure resembles response
prevention as applied in the treatment of obsessive–compulsive disorder (OCD).
Yet, unlike in the treatment of OCD, in which response prevention is used to alter
predicted external threat, in PGD treatment it is used to confront valid thoughts
and feelings that have to be dealt with in treatment.
Behavioral activation is an important intervention in targeting depressive
avoidance. In behavioral activation, people are instructed to register activities
and mood for some days or weeks, in order to experience how activity improves
mood. Then, behavioral interventions are applied to help the person to reengage
in rewarding activities (Jacobson et al., 2001). In addition, treatment could focus
on identification of social, occupational, or recreational goals, and planning
actions necessary to achieve goals. Dependent on the nature of the goals, this
can be accompanied by social skill training, problem-solving skill training, and
time management training (Jacobson et al., 2001). Personal goal work is also
central to “complicated grief treatment” (Shear et al., 2011); it is based on the
idea that working toward the achievement of valued goals fosters the experi-
ence of positive emotions, the ability to solve problems, and the motivation to
confront painful information. In behavioral activation, there is a clear focus on
action, irrespective of certain aversive thoughts and mood states. A key idea
behind this approach is that it is not necessary to change mood before behavior
can be changed but, on the contrary, behavior change can precede improvement
of mood. A further idea is that activation and working toward the achievement
of valued goals can facilitate self-clarity and a continued sense of self (Ehlers,
2006).

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 Prolonged grief disorder 229

Research on CBT theory and treatment for PGD

In this section we will review evidence that supports the CBT theory and treat-
ment of PGD.

Theory
Because the underpinnings of CBT for PGD draw heavily on existing cogni-
tive–behavioral theorizing (Beck, 1976; Dalgleish, 2004; Ehlers & Clark, 2000),
the extensive body of evidence supporting the view that unhelpful thoughts,
behaviors, and memory processes indeed work in concert, maintaining all kinds
of emotional suffering, provides indirect support for the CBT approach to PGD.
However, an increasing number of studies have directly investigated causes and
correlates of PGD from the perspective of CBT.
For instance, earlier research findings of a linkage between grief severity
and negative views about meaningfulness of the world and the worthiness of
the self (Schwartzberg & Janoff-Bulman, 1991) and self-blame and other-blame
(Field & Bonanno, 2001) accord with the importance of negative cognitions in
grief. In several of our own studies, we found evidence for a significant linkage
between negative cognitions and assumptions and PGD severity. For instance,
in a prospective study, stronger endorsement of negative assumptions about the
self, life, and the future in the early stages of grief predicted more severe PGD
and depression across 2 years post-loss (Boelen, van den Bout, & van den Hout,
2006). Furthermore, in cross-sectional and prospective studies (Boelen, van den
Bout, & van den Hout, 2003, 2010), we found evidence that catastrophic misin-
terpretations of grief reactions were associated with more severe PGD as well as
with tendencies to experientially avoid the pain of the loss. The importance of
these misinterpretations in predicting PGD was also supported in a large-scale
longitudinal study by Van der Houwen, Stroebe, Schut, Stroebe, and van den Bout
(2010).
Research has also provided evidence for the importance of avoidance behaviors
in PGD. For instance, generic measures of deliberate avoidance of loss-related
stimuli have been found to be significantly associated with loss-related distress in
several studies (e.g., Bonanno, Papa, Lalande, Nanping, & Noll, 2005; Shear et al.,
2007). In a cross-sectional study, we found evidence that indices of situational and
cognitive avoidance were associated with PGD (Boelen & van den Hout, 2008).
Importantly, the strength of the association was stronger in mourners who strongly
endorsed catastrophic misinterpretations, attesting to the notion that avoidance
strategies interact with catastrophic misinterpretations in maintaining PGD. A
further cross-sectional study showed that anxious and depressive avoidance are
separate constructs having distinct associations with PGD severity (Boelen & van
den Bout, 2010). Several studies have pointed at a linkage between PGD and
difficulties to retrieve specific memories (e.g., Chapter 13 in this volume). Given
that such difficulties are assumed to reflect avoidant tendencies, these studies also
support the importance of avoidance in maintaining PGD.

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230 Paul A. Boelen et al.
Relatively few studies have as yet addressed the hypothesis that PGD is asso-
ciated with a lack of connectivity between explicit knowledge of the loss and
implicit memory knowledge. Although this is mainly an implicit process occur-
ring at the level of the autobiographical memory base, it is postulated to manifest
itself in at least two introspectively accessible phenomena. The first is a sense of
unrealness that can be defined as a subjective sense of uncertainty or ambivalence
about the irreversibility of the separation. The second is a reduced sense of clarity
about the self. In a series of studies we found evidence that increased levels of
PGD are indeed associated with a greater sense of “unrealness” about the loss
(even when controlling for negative cognitions, avoidance, and concomitant
depression) and with an impaired sense of self-clarity (Boelen, 2010; Boelen et
al., 2012). Two studies by Maccallum and Bryant provided further support for a
linkage between PGD and insufficient emotional processing at the level of auto-
biographical memory. In the first of these, they found people with PGD to report
more self-defining memories (i.e., vivid memories comprising enduring concerns
about the self) related with the lost person than people without PGD (Maccallum
& Bryant, 2008). This can also be taken as evidence that PGD is associated with
an impairment in the adjustment of self-representational knowledge. In a second
study, PGD patients were found to have an attentional bias for information related
with death and separation (Maccallum & Bryant, 2010) – a finding that accords
with the notion that PGD is characterized by a reduced integration of such knowl-
edge with other autobiographical knowledge.
Two studies provided evidence for the hypothesis that a lack of integration,
negative thinking, and avoidance behaviors indeed mediate the impact of estab-
lished personality-related and situational risk factors on PGD severity. In a cross-
sectional study, these three processes were found to mediate the associations of
neuroticism and attachment insecurity with PGD severity (Boelen & Klugkist,
2011). In a longitudinal study by Van der Houwen et al. (2010), catastrophic mis-
interpretations were found to mediate the impact of several risk factors on PGD,
including gender, neuroticism, and expectedness of the death.

Treatment
CBT has consistently been found to be an effective treatment for a wide range
of disorders (Beck, 2005). Again, this indirectly supports the relevance of this
approach for treating PGD. More direct evidence for the effectiveness of CBT
interventions comes from early studies by Mawson, Marks, Ramm, and Stern
(1981) and Sireling, Cohen, and Marks (1988). In these studies, exposure to loss-
related stimuli was found to lead to reduction in symptoms of problematic forms
of grief. As noted, some of the more recently conducted treatment studies have
also provided evidence for the effectiveness of CBT for PGD. In a large trial,
Shear et al. (2005) compared the effectiveness of “complicated grief treatment”
with the effects of interpersonal psychotherapy. The former treatment was signifi-
cantly more effective in terms of effect sizes and time to response than the latter
approach. Wagner et al. (2006) subjected patients with PGD to an Internet-based

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 Prolonged grief disorder 231
CBT treatment. In comparison with patients in a waiting-list control group, those
who underwent the treatment experienced a greater reduction in PGD and related
symptoms.
In our own treatment trial we randomly allocated 54 people with PGD to one
of three treatments: one of two CBT treatments or non-directive supportive treat-
ment (Boelen et al., 2007). The two CBT conditions consisted of six 45-minute
manual-based sessions of cognitive restructuring (CR) and six sessions of expo-
sure therapy (ET) applied in two orders (CR + ET and ET + CR). The six sessions
of CR focused on explanation of the rationale of CR and learning to identify,
dispute, and alter negative cognitions. ET sessions included narrating the story of
the loss in detail, identification of internal and external reminders of the loss that
were avoided, and gradual confrontation with these reminders. Different forms of
exposure were used (e.g., exposure in vitro when patients avoided particular mem-
ories, response prevention when they engaged in compulsive proximity-seeking
behaviors). Results showed that symptoms of PGD and general psychopathology
declined significantly more in people allocated to the CBT treatments than in
those allocated to supportive counseling. For instance, in the intention to treat
analysis, pre-treatment to post-treatment effect sizes (Cohen’s d) on the Inventory
of Complicated Grief, a well-validated measure of PGD (Prigerson et al., 1995),
were 0.87 for the CR + ET condition and 1.29 for the ET + CR condition, com-
pared with 0.42 for the counseling condition. Effect sizes for CBT conditions are
large according to conventional guidelines and resemble the effect size of 1.35 in
the intention-to-treat analyses found by Shear et al. (2005) for their PGD treat-
ment. In follow-up analyses, we found that stronger reduction in PGD severity
was significantly associated with stronger reductions in negative cognitions and
avoidance. Although this was not a formal test of mediation, outcomes support the
relevance of targeting negative thinking and avoidance in the treatment of PGD
(Boelen, de Keijser, van den Hout, & van den Bout, 2011).

Closing comments
In CBT perspectives on PGD (Boelen, van den Hout, & van den Bout, 2006; Shear
et al., 2005, 2011; Wagner et al., 2006) it is hypothesized that memory processes,
negative cognitions, and avoidance behaviors play a key role in the development
and maintenance of PGD. As outlined in this chapter, there is increasing evidence
supporting this hypothesis. Nonetheless, more work needs to be done to test basic
premises of CBT perspectives on PGD. For instance, studies conducted to date
have mostly relied on self-report measures. It would be relevant for future stud-
ies to use other methods to study the role of memory processes, cognitions, and
behaviors in PGD, including methods based on social cognition and diary-keeping
methods to map out avoidance behaviors. In addition, experimental research is
needed to test the proposed directions of causality between variables.
More work obviously also needs to be done in the area of CBT treatment for
PGD. Although the findings summarized in this chapter support the potential
strength of CBT as a treatment of PGD, there is still ample scope for improving

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232 Paul A. Boelen et al.
this treatment. For instance, in our own study (Boelen et al., 2007), only 32.6%
of patients randomly assigned to the CBT conditions showed clinical significant
reductions in PGD severity. This being the case, it seems important to further
refine the recent promising treatments. It is important for future studies to try to
disentangle the effects of specific components of treatment for specific subgroups
of people suffering PGD. It is also important to enhance clarity on mechanisms
of change of CBT, that is, whether or not CBT indeed produces alleviation of dis-
tress because it lessens negative cognitions and avoidance. Notwithstanding these
considerations, there are reasons to be optimistic about the explanatory value and
clinical usefulness of applying cognitive–behavioral theorizing to the study and
treatment of persons with PGD.

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