CBT more effective than mindfulness therapy for prolonged grief disorder, but both extend help

Grief-focused cognitive behaviour therapy (CBT) and mindfulness-based cognitive therapy are both beneficial to individuals with prolonged grief disorder, although CBT is associated with greater symptom reductions, as shown in a study.

After 6 months of treatment, participants who received grief-focused CBT had significantly lower symptom scores on the Prolonged Grief−13 (PG-13) scale compared with those who received mindfulness-based cognitive therapy (mean difference, 7.1, 95 percent confidence interval [CI, 1.6–12.5; p=0.01), with a large between-group effect size (0.8, 95 percent CI, 0.2–1.3). [JAMA Psychiatry 2024;doi:10.1001/jamapsychiatry.2024.0432]

Additionally, grief-focused CBT was associated with significantly greater reductions in depression as measured on the Beck Depression Inventory (mean difference, 6.6, 95 percent CI, 0.5–12.9; p=0.04) and in grief-related cognition (mean difference, 14.4, 95 percent CI, 2.8–25.9; p=0.02).

None of the participants experienced any adverse events attributed to the interventions.

“There were no discernible differences in prolonged grief disorder reduction between the two interventions at post-treatment, and the superiority of grief-focused CBT was only apparent at the 6-month assessment,” the investigators noted.

Addressing the loss

Grief-focused CBT and mindfulness-based cognitive therapy took different approaches to tackling prolonged grief disorder. Grief-focused CBT targeted memories and thoughts about the loss. It helped the participants identify and reframe negative thinking patterns through cognitive reframing techniques.  In contrast, mindfulness-based cognitive therapy equipped participants with mindfulness skills to manage the difficult emotions and thoughts that arise from grief. The focus was to consider these emotions and thoughts without judgment, allowing for a more accepting experience of grief.

“Whereas both interventions provided reduction in distress while the strategies were being learned and rehearsed, the grief-focused CBT had longer-term benefits because it directly addressed some of the mechanisms that purportedly drive prolonged grief disorder symptoms,” the investigators pointed out.

On the other hand, while mindfulness-based therapy may have helped manage symptoms during the study, it is possible that the intervention did not lead to lasting improvement because the emotion regulatory approach applied did not directly address the core issues of grief, such as memories of the death and beliefs about the loss, they explained. [J Consult Clin Psychol 2007;75:277-284; JAMA Psychiatry 2014;71:1332-1339]

“This interpretation accords with the observation that grief-focused CBT reduced maladaptive cognitions about the loss to a greater extent than mindfulness-based cognitive therapy, and evidence that reducing grief-related cognitions is a key factor in resolution of prolonged grief disorder,” the investigators said. [Clin Psychol Psychother 2011;18:284-291]

“Grief-focused cognitive behaviour therapy also resulted in greater reduction of depression symptoms relative to mindfulness-based cognitive therapy… [T]he greater reduction [in] depression in participants receiving grief-focused CBT may be attributed to the superior reductions in prolonged grief disorder severity, thereby leading to downstream decreases in depression. We also note that grief-focused CBT comprised goal setting, promotion of positive activities, and relapse prevention, which can also contribute to reduced depression,” they added. [Psychother Res 2020;30:279-293]

The study included 100 adult participants (mean age 47.3 years, 87.0 percent female) with prolonged grief disorder. These participants were randomly assigned to undergo grief-focused CBT (n=50) or mindfulness-based cognitive therapy (n=50). Both interventions consisted of once-weekly 90-minute individual sessions conducted for 11 weeks. Grief-focused CBT sessions involved recalling memories of the deceased plus cognitive restructuring and planning future social and positive activities. Mindfulness-based cognitive therapy sessions focused on mindfulness exercises adapted to tolerate grief-related distress.