Holly Prigerson and colleagues tested the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.

Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This paper focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.

Previous quantitative reviews of research on the efficacy of psychotherapy for depression have included only a subset of the available research or limited their focus to a single outcome measure. The present review offers a more comprehensive quantitative integration of this literature. Using studies that compared psychotherapy with either no treatment or another form of treatment, this article assesses (a) the overall effectiveness of psychotherapy for depressed clients, (b) its effectiveness relative to pharmacotherapy, and (c) the clinical significance of treatment outcomes. Findings from the review confirm that depressed clients benefit substantially from psychotherapy, and these gains appear comparable to those observed with pharmacotherapy. Initial analysis suggested some differences in the efficacy of various types of treatment; however, once the influence of investigator allegiance was removed, there remained no evidence for the relative superiority of any 1 approach. In view of these results, the focus of future research should be less on differentiating among psychotherapies for depression than on identifying the factors responsible for improvement. Depression is a prevalent clinical disorder with high economic and emotional costs. Epidemiological research has indicated that 10%-20% of the population experience a major depressive episode at some point in their lifetime (Boyd & Weissman, 1981), with the incidence highest during the adult years when family and career responsibilities may be most adversely affected (Weissman & Myers, 1978). Although the remission rate for depressive disorders is relatively high (Beck, 1967, chap. 3), a substantial portion of those afflicted remain chronically depressed (Weissman & Klerman, 1977), and those who do improve are at an increased risk for further episodes (Belsher & Costello, 1988;Kessler, 1978; Klerman, 1978). Until recently, depression was treated almost exclusively with medication, traditional insight-oriented therapy, or a combination of the two. However, the 1970s witnessed the development of a number of new therapeutic approaches, each of which pos

A comprehensive quantitative review of published randomized controlled outcome studies of grief counseling and therapy suggests that such interventions are typically ineffective, and perhaps even deleterious, at least for persons experiencing a normal bereavement. On the other hand, there is some evidence that grief therapy is more beneficial and safer for those who have been traumatically bereaved. Beginning with this sobering appraisal, this article considers the findings of C.G. Davis, C.B. Wortman, D.R. Lehman, and R.C. Silver (this issue) and their implications for a meaning reconstruction approach to grief therapy, arguing that an expanded conception of meaning is necessary to provide a stronger basis for clinical intervention.

Constructivist theories recently have begun to inform understandings of grief, emphasizing the role of meaning making in adaptation to bereavement. In this article we review empirical studies using qualitative, quantitative, and mixed methods, investigating how three activities of meaning reconstruction are involved in the grieving process: sense making, benefit finding, and identity change. In particular, we consider how critical processes have been operationally defined and how study methods and designs have constrained what can be concluded from this burgeoning field of research. We conclude by positing an integrated model of meaning reconstruction pathways as a heuristic guide to further research and briefly note the implications of this model for clinical practice.Victor Frankl's (1962) seminal work, Man's Search for Meaning, asserted that people are driven by a psychological need to find or create a sense of meaning and purpose in their lives, and that this drive can facilitate their capacity to face and transcend even the most horrific of experiences. This theme has struck a deep chord not only in psychology, but also in philosophy, art, literature, and

Previous quantitative reviews of research on psychotherapeutic interventions for bereaved persons have yielded divergent findings and have not included many of the available controlled outcome studies. This meta-analysis summarizes results from 61 controlled studies to offer a more comprehensive integration of this literature. This review examined (a) the absolute effectiveness of bereavement interventions immediately following intervention and at follow-up assessments, (b) several of the clinically and theoretically relevant moderators of outcome, and (c) change over time among recipients of the interventions and individuals in no-intervention control groups. Overall, analyses showed that interventions had a small effect at posttreatment but no statistically significant benefit at follow-up. However, interventions that exclusively targeted grievers displaying marked difficulties adapting to loss had outcomes that compare favorably with psychotherapies for other difficulties. Other evidence suggested that the discouraging results for studies failing to screen for indications of distress could be attributed to a tendency among controls to improve naturally over time. The findings of the review underscore the importance of attending to the targeted population in the practice and study of psychotherapeutic interventions for bereaved persons.

This study examined the relative contribution of objective risk factors and meaning-making to grief severity among 157 parents who had lost a child to death. Participants completed the Core Bereavement Items (CBI; Burnett, Middleton, Raphael, & Martinek, 1997), Inventory of Complicated Grief (ICG; Prigerson et al., 1995), questions assessing the process and degree of sense-making and benefit-finding, and the circumstances surrounding their losses. Results showed that the violence of the death, age of the child at death, and length of bereavement accounted for significant differences in normative grief symptoms (assessed by the CBI). Other results indicated that the cause of death was the only objective risk factor that significantly predicted the intensity of complicated grief (assessed by the ICG). Of the factors examined in this study, sense-making emerged as the most salient predictor of grief severity, with parents who reported having made little to no sense of their child's death being more likely to report greater intensity of grief. Implications for clinical work are discussed.

Drawing on attachment theory and constructivist conceptualizations of bereavement, the authors assessed the relation between continuing bonds coping and meaning reconstruction following the death of a loved one and complicated grief symptomatology. Five hundred six young adults in the first two years of bereavement from a variety of losses completed the Inventory of Complicated Grief along with measures of the strength of their ongoing attachment to the deceased and their capacity to make sense of the loss, find benefit in the experience, and reconstruct a progressive sense of identity following the death. Several variables concerning the survivor, his or her relationship to the deceased, and the nature of the death functioned as risk factors for heightened distress, but their role was generally moderated by meaning-making, often to the point of non-significance. In contrast, higher levels of benefit-finding and positive identity change were associated with lower levels of bereavement complication. Finally, an interaction emerged between sense-making and ongoing attachment to the deceased, suggesting that strong continuing bonds predicted greater levels of traumatic and especially separation distress, but only when the survivor was unable to make sense of the loss in personal, practical, existential, or spiritual terms.