Research Article

Theoretical-practical Guidelines for Mental Health Professionals on Complicated Grief: a Systematic Review Based on Narrative Therapy

Petra Santos¹ and Luísa Soares*

Faculty of Arts and Humanities, Department of Psychology, University of Madeira, Portugal

Submission: July 30, 2024; Published: August 20, 2024

*Corresponding author: Luísa Soares, Faculty of Arts and Humanities, Department of Psychology, University of Madeira, Portugal

How to cite this article: Santos P , Soares L. Theoretical-practical Guidelines for Mental Health Professionals on Complicated Grief: a Systematic Review Based on Narrative Therapy. Psychol Behav Sci Int J. 2024; 22(1): 556080. DOI: 10.19080/PBSIJ.2024.22.556080.

Abstract

This article aims to present theoretical-practical guidelines for mental health professionals based on a systematic review of the literature, guided by PRISMA (Method Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Page et al. [1], which explored the contributions of narrative therapy and constructivist-narrative strategies in the integration of complicated grief into normal grief. The literature needs to demonstrate more effectiveness in primary interventions, showing better results in secondary and tertiary interventions [2,3]. This work focuses on tertiary intervention (complicated grief), especially narrative therapy [4], an extension of cognitive-behavioral therapy based on a postmodern constructionist perspective [5]. It proposes 8 theoretical guidelines -practices for intervention with people in complicated grief.

Keywords: Complicated Grief; Narrative Therapy, Theoretical Guideline Practices; Intervention

Abbreviations: PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses, DSM-V: Diagnostic and Statistical Manual of Mental Disorders-V, ICD: International Classification of Diseases

Introduction

Grief is a universal and complex experience that accompanies the loss of a loved one. It is a natural and inevitable process in the human experience, which can become a significant emotional challenge when it evolves into complicated grief, whose suffering becomes intense and disabling [6-9]. Recognition of the disorder and preliminary strategies for its intervention are crucial to prevent and act on additional difficulties to individuals’ mental health. Despite the clinical and social relevance of complicated grief, this article aims to present theoretical-practical guidelines for mental health professionals based on a systematic review of the literature, guided by PRISMA (Method Preferred Reporting Items for Systematic Reviews and Meta-Analyses [1], which explored the contributions of narrative therapy and constructivist-narrative strategies in the integration of complicated grief into normal grief. The work addresses different aspects of complicated grief, from understanding the different nomenclatures to identifying the main risk factors. Furthermore, it aims to demonstrate the impact of grief on childhood, emphasizing the need for adaptive approaches that consider the age, level of functioning and intellectual capabilities of children [10,11]. Integrative treatments are highlighted for their effect on emotional adaptation and reconstruction of meaning after loss [12-15]. Therapeutic writing, in particular, is approached as an accessible, low-cost strategy that promotes self-awareness and integration of the grief experience [16]. Online interventions emerge as a promising alternative, demonstrating comparable effectiveness to in-person approaches and offering practical solutions to economic and mobility barriers [17,18]. Group therapies are also discussed, highlighting their benefits in terms of social support, sharing experiences and developing a sense of community [19]. The aim is to offer a theoretical perspective to mental health professionals in order to support therapeutic choices. The importance of personalized interventions, adapted and sensitive to individual needs, is highlighted. By emphasizing the diversity of therapeutic strategies available, the study promotes more informed and effective clinical practice in the treatment of complicated grief.

What is complicated grief?

The death of a loved one is a universal and inevitable event, predisposing the grieving process, which can be rich in memories and emotions. However, it can also be painful and trigger a variety of physical, emotional, cognitive, behavioral and social symptoms [20-23]. When the grieving process is prolonged in frequency, severity and chronicity, emotions and feelings remain persistently intense and distressing [24,25], resulting in the complication of normal grief [6,8]. The literature encompasses several terms to refer to the non-integrative, complicated and prolonged process of grief, namely: chronic grief, prolonged grief, complicated grief, maladaptive grief, postponed grief, pathological grief, delayed grief, distorted grief, unresolved grief, abnormal grief, dysfunctional grief and traumatic grief [26-31,25]. This article will use the term ‘complicated grief’ to refer to grief disorder due to its greater prevalence and association in the literature [28, 32- 34].

Diagnosis and Classification of Complicated Grief Disorder

DSM-V and ICD-11 perspectives

The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) initially defined this non-normative grieving process as a persistent complex grief disorder. This disorder presents criteria that include the experience of the death of a loved one and the presence of cognitive, emotional and behavioral symptoms such as persistent longing for the deceased, intense emotional pain, concern about the loved one and the circumstances of the death, difficulties in accepting the death, emotional numbness, difficulties in positively remembering the loved one, anger, maladaptive evaluations and excessive avoidance of memories. Aspects of social and identity disturbance are also observed: the desire to die and be reunited with the deceased, difficulties in trusting, loneliness, lack of meaning in life, reduced sense of identity, lack of interpersonal interest and lack of carrying out activities and plans [35]. These symptoms must persist for at least 12 months after the loss in adults and six months in children, this being the time interval necessary to differentiate normal grief from persistent complex grief disorder [35]. The International Classification of Diseases-11 (ICD-11) identifies the complicated grieving process as a prolonged grief disorder [36], with criteria parallel to the DSM-V. It adds criteria related to persistent and generalized desire and longing for the loved one, guilt and selfblame, denial and confusion [37-39]. According to ICD-11, prolonged grief disorder is present six months after the loss [8, 37-39]. In an attempt to harmonize persistent complex grief disorder with prolonged grief disorder, a group of researchers met in June 2019 [29] and concluded that the revised version of the DSM-V integrates the disorder of prolonged mourning, with this diagnosis being approved in November 2020 [40, 9, 29]. The diagnostic criteria remain corresponding to previous versions [37, 9, 29, 38].

Risk Factors of Complicated Grief Process

Studies over the years have identified several risk factors for complicated grief, which are crucial for understanding, planning, and implementing effective psychological interventions [41, 42, 20, 23, 31].

Relational Intimacy

The first risk factor identified is that of relational intimacy. The significance of the loved one in the life of the grieving individual is fundamental in determining the grieving process. Complicated grief is associated with close losses, especially in intimate parentchild and spouse relationships [43-49,37]. Relational factors such as degree of kinship, level of emotional attachment and proximity are identified as risky, especially in ambivalent, narcissistic and dependent relationships [50-52, 46, 42, 31]. Marital dependency is highlighted as a significant risk factor for complicated grief [42], along with separation anxiety, childhood abuse or neglect, authoritarian or permissive parenting, and insecure, anxious, and avoidant attachment [41, 49, 37].

Nature and Circumstances of Death

Premature, sudden, multiple, unexpected, violent, traumatic deaths, as well as suicides, are considered powerful risk factors for the development of complicated grief. Deaths resulting from disabling and prolonged illnesses are also associated with complicated grief [41-43, 22, 53, 23, 31, 54].

Individual Characteristics

The socioeconomic, psychological, psychosocial, physiological and physical characteristics of the grieving individual, along with personality factors and personal and clinical history, play an important role in the progress of complicated grief [3]. Individual particularities such as age, gender (female), lack of preparation or fear in relation to death, emotional expression or absence, high neuroticism, external locus of control, obsessive traits, previous experiences of unresolved losses, diminished self-concept, styles of maladaptive coping (rumination and avoidance), search for meaning, the presence of mental disorders and the use of addictive substances, influence the typical reactions of complicated grief [35, 41-43, 45, 51, 3, 49, 31, 52].

Contributions of Narrative Therapy in the Complicated Grief Process

The complicated grieving process is emotionally challenging and causes intense suffering, requiring multidimensional psychological interventions specific and adapted to the loss [55, 56, 23]. Waller et al. [30] classify these psychological interventions into three levels: primary (for normal grief), secondary (for risk groups) and tertiary (for individuals with complicated grief symptoms). The literature needs to demonstrate more effectiveness in primary interventions, showing better results in secondary and tertiary interventions [2,3]. This topic focuses on tertiary intervention, especially narrative therapy [4], an extension of cognitive-behavioral therapy based on a postmodern constructionist perspective [5]. Narrative therapy aims to increase the coherence, complexity and multiplicity of the client’s discursive construction, promoting development, freedom and creativity [57]. It is relevant in complicated grief, especially in difficulties in adapting to loss and in the manifestation of negative emotions. These controversies are often related to the resistance of the grieving individual to rebuild a new reality after the loss of a loved one [21]. Complicated grief, linked to the loss of identity, finds a reparative path in narrative therapy, given the therapeutic objective of deconstructing the dominant narrative and collaborating in the co-authorship of a coherent narrative, formulating new possibilities for the self [58]. Individuals with complicated grief often express problematic narratives that distort temporal perception and are centered on intense suffering.

These narratives reflect an irrecoverable past and the difficulty of envisioning a meaningful future, leading to the loss of meaning in life [59]. Narrative therapy can transform them, discovering unique results, following the phases of deconstruction (separation from loss of identity), reconstruction (co-creation of adaptive narratives) and consolidation (internalization and integration of new narratives into the identity, promoting meaning and purpose [60, 4]). The elaboration of new narratives allows the individual to adjust to reality without the deceased [61]. Neimeyer [62] highlights the importance of reconstructing meaning, enabling the grieving individual to develop self-efficacy and hope. Redefining the relationship with the deceased as a symbolic presence is essential, promoting emotional relief and adaptation [63, 25].

Constructivist-Innovative Narrative Strategies in Complicated Grief

Neimeyer [63] highlights the importance of metaphorical, poetic and narrative strategies, which go beyond direct verbalization, especially in cases of complicated grief. Ricks et al. [64] highlight creative narrative strategies such as photography, films, works of art, writing and music. These tools favor expression and narrative reconstruction, helping to create new perspectives on the problems faced by the grieving individual.

Expression through Art: In the context of expressive arts, different forms of therapy are used [64]:

i. Phototherapy: Clients use photography to describe the world from their perspective, expressing feelings, memories and experiences through the images captured. Phototherapy allows for self-exploration and self-direction and helps to understand emotions and figurative contexts.

ii. Films: Promising tools for discussing feelings, exposures, and personal experiences. Clients take on the role of directors, reconstructing and retelling their life narratives through the analysis of stories represented by actors; in other words, they become directors of the film.

iii. Music: In narrative therapy, music can be used to express difficult emotions, with lyrics that symbolize stories, fostering open and exploratory conversations.

Therapeutic Writing: Writing is an effective therapeutic intervention in health and wellbeing, as it helps with psychological suffering and promotes positive effects [65]. Studies over the years have demonstrated benefits regarding the reduction of symptoms of anxiety and depression, in addition to promoting physical and mental health and increasing awareness of personal and relational meanings. These benefits are observed when writing about painful and pleasurable aspects of life [66-69]. According to the literature, therapeutic writing in narrative therapy produces positive results in individuals with problematic narratives, due to its ability to reconstruct alternative narratives, focus on unique results, explore interpersonal factors, and be culturally applicable [58]. It is a crucial reflective strategy, offering therapeutic effects and a personal experience free from external criticism and judgment. It can be used alone or as a complement to therapy, addressing individual variables such as cognition and emotion [70]. Therapeutic writing facilitates the organization and integration of traumatic experiences, promoting changes in the coherence of the story [70,71]. Writing about traumatic events helps clients identify and accept their emotions, leading to greater emotional control and the ability to cope with painful experiences [72]. Lima and Fortim [73] highlight the importance of writing in preserving the memory of the deceased. Paiva and Rasera [74] and Ricks et al. [64] also highlight that writing increases clients’ awareness of their distressing experiences, offering a deeper internal understanding. Larsen [16] emphasizes that this technique allows grieving individuals to self-reveal, resolve outstanding issues with the deceased, continuously create bonds and happy memories, and appropriate a coherent narrative in the face of loss. Therapeutic writing in grief includes farewell letters, reflections on one’s own identity, perspectives of significant others, moments shared with the deceased and reflections on the life story [75,22]. However, it may initially evoke pain, especially when remembering traumatic aspects of the death [71]. However, Pennebaker [76] argues that in the long term, pleasurable emotions tend to prevail, resulting in the client’s greater perception of the present and the future, which gives a new meaning to their new reality.

Other Ideal Therapeutic Strategies for Treating Complicated Grief: Narrative retelling allows the grieving individual to repeatedly retell the story of their loved one’s death, focusing on characters, relationships, emotional crises, and beliefs [75]. The therapist plays a decisive role in facilitating the client’s emotional expression and reflection on the meaning of the loss. This strategy, whether orally or in writing, is particularly useful in traumatic deaths such as suicide, homicide or accidents [75]. Implemented progressively throughout treatment, it aims to reduce anguish, promote the extinction of avoidance mechanisms and explore meanings, contributing to the development of resilience [75,22] and the integration of the experience of death [25]. When using narrative retelling, professionals must recognize that the reactions of grieving individuals may vary and that the process is gradual, initially risking increasing distress, before perpetuating noticeable improvements [26]. Imaginary conversations are flexible and crucial therapeutic strategies for the assimilation and integration of the loss narrative, especially when focusing on the interpersonal dimension. In other words, they allow the grieving individual to access and transform the story of death, emphasizing, above all, the relationship with the deceased [75].

In the therapeutic approach to complicated grief, it is essential to separate the loss from the client’s identity. The therapist can invite the client to assign a name to the grieving process, facilitating this distinction. Externalizing is useful for exploring the impact of grief on different areas of the client’s life and identifying external coping resources, promoting a more flexible and compassionate view of the death experience. Regarding the remembering strategy, White [58] defends its applicability in mourning, directing attention to neglected aspects of life in addition to the loss that dominates the narrative.

Methodology

This study is a qualitative descriptive approach and uses data and conclusions from a systematic review of the literature carried out on the contributions of narrative therapy and constructivistnarrative strategies in the complicated grieving process. The systematic literature review followed the PRISMA guidelines [1]. The research objectives were: (i) to present theoretical-practical guidelines for mental health professionals in the treatment of complicated grief; (ii) analyze the main risk factors for complicated grief; (iii) examine the impact of complicated grief in childhood; (iv) present the effectiveness of different therapeutic strategies based on narrative therapy.

The article was conducted based on the following research questions:

1. What are the most efficient theoretical-practical guidelines for treating complicated grief?

2. How to intervene in grief in children and adolescents?

3. What are the most relevant risk factors for the development of complicated grief?

4. How does therapeutic writing contribute to the integration and adaptation of complicated grief?

5. How important are adapted and individualized interventions for the treatment of complicated grief?

Research strategy

A systematic literature search was performed based on key keywords related to narrative therapy and complicated grief, using Boolean operators OR and AND to ensure an inclusive and accurate approach. The terms “Narrative Therapy,” “Narrative Clinical Psychology,” “Therapeutic Writing,” “Narrative Change,” and “Narrative Reconstruction” were included to encompass a variety of therapeutic interventions and narrative-based strategies. The terms “Prolonged Grief Disorder,” “Long-lasting Grief,” and “Complicated Grief” were added to ensure the relevance of the selected studies to the topic under analysis. The databases used were Google Scholar, B-On, PubMed, Springer Link, Taylor and Francis, Web of Science and Science Direct. The search was carried out predominantly in English, with the exception of the Google Scholar database, which was also carried out in Portuguese, due to the greater probability of providing master’s and doctoral dissertations.

Selection criteria

The inclusion criteria were: (a) a period of 23 years (2000- 2023); (b) worldwide research studies; (c) studies in Portuguese and English; (d) master’s and doctoral dissertations; (e) Scientific, review and systematic literature review articles; (f) studies with narrative therapy as an intervention for complicated grief; (g) studies with therapeutic writing as an intervention strategy for complicated grief; (h) studies with constructivist-narrative strategies as an intervention for complicated grief; (i) studies whose sample reveals the presence of complicated grief; (j) open access studies. On the other hand, studies that did not meet the following criteria were excluded: (a) they were not within the predefined period; (b) did not address the themes under analysis; (c) they did not list the keywords; (d) were not open access.

Study selection

The selection of studies for the systematic literature review took place between September 2023 and January 2024. The PRISMA 2020 flowchart (figure 1) illustrates the review process, which included the identification of duplicate articles, selection by title and abstract, checking the full text and reading the studies in full. (Figure 1).

General Guidelines for Clinical Practice with Individuals with Complicated Grief

The theoretical framework and conclusions of the systematic literature review carried out were crucial for the development of theoretical-practical guidelines for mental health professionals, regarding the treatment of complicated grief. This section addresses how sound scientific knowledge can inform and guide evidence-based clinical interventions tailored to the specific needs of grieving individuals.

Clarification of the Nomenclature of Grief Disorder

The literature on complicated grief is made up of a variety of similar terms. Its different conceptualizations recommend the relevance of understansding it for competent clinical practice. The investigation resulting from the systematic literature review analyzed studies with different nomenclatures for complicated grief, from ‘complicated grief,’ ‘prolonged grief disorder,’ ‘persistent complex grief disorder,’ and ‘traumatic grief.’ Their definitions may overlap or diverge, depending on the context and authors. Complicated grief refers to a grief reaction that significantly interferes with the individual’s daily functioning due to persistent difficulty accepting the loss, emotional intensity, and inability to continue with daily activities [39, 9, 23].

Persistent complex grief disorder and prolonged grief disorder are formal diagnoses introduced in DSM-V and ICD- 11, sharing characteristics of complicated grief, delimiting the specific duration to be considered as psychopathology (12 and six months[ 35, 38, 39] Traumatic grief is referred to when the nature of the loss involves a traumatic context, such as sudden and violent deaths, classified as risk factors for the development of complicated grief [35, 41- 43, 23, 31, 52-54]. It is hoped that the presentation of the nomenclatures of grief disorder will contribute to the exposure of the various terms used in the context of complicated grief and subsequent differentiation from normal grief, also allowing increased awareness of the consequences and risk factors of the phenomenon.

Risk Factors: female gender, parent-child relationships and spouses

In the systematic review, studies that investigated the effectiveness of narrative therapy in complicated grief in different loss contexts were included. It was observed that constructivistnarrative strategies appeared to be flexible and effective, capable of adapting to the specific needs of grieving individuals, regardless of the circumstance, type of loss and relationship with the deceased. Considering that the general public of the reviewed interventions was female [77-85, 12, 13, 22] mental health professionals must be particularly attentive to women who have faced a recent loss, within six months, in order to prevent the development of complicated grief. On the other hand, for those who have already faced the loss for more than six months, the application of narrative strategies can be a method to implement, given the possibility of reorganizing the loss experience, building new meanings and maintaining a continuous bond with the loved one. Dear. This research calls on health professionals to use these strategies as part of the treatment and support for grieving women. The analysis confirmed that complicated grief is strongly related to the depth of the emotional bond and mutual support of parent-child relationships [77-81, 12, 2021, 15, 86-92, Bryant et al. 2014, 2015, 85] reinforcing the need for reflection in cases of grief with these types of relationships, as they lead to serious and disabling psychological consequences. Traumatic deaths [82, 92-97], suicide [Bryant et al. 2014,13, 83, 98-101, 95, 88, 92] and originating from diseases [78-81, 12, 102, Bryant et al. 2014, 13, 92], disseminate intense emotional distress, feelings. Of guilt and anger, social isolation and difficulties in accepting the new reality. The results achieved highlight the need for support and in-depth insight into the circumstances of death and individual needs. The systematic review helped in this aspect by presenting and analyzing effective interventions for processing feelings and reconstructing meanings. Mental health professionals must approach each case individually, considering the need for holistic support, which emphasizes the emotional aspects and personal and circumstantial characteristics of the grieving individual.

Internalization and Understanding of Grief by Children

Grief in childhood is an adverse event and interferes with children’s mental and physical autonomy. The loss of someone significant during this period can have a profound impact on the process of growth and maturation. Serra et al. [11] indicate three fundamental concepts in the internalization and understanding of grief by children: irreversibility (knowledge of the permanence of death), non-functionality (understanding that death implies the loss of life functions) and universality (perception that all beings living die). Children may express difficulty in understanding death due to their age and cognitive development, exposing limited insight into the definitive loss of a significant loved one, compared to adults, who have a full understanding of the permanence and universality of death [50, 10]. With the investigation of the literature, it was observed that the adaptation of strategies to deal with the symptoms and reactions of grief in children and adolescents, according to their age, level of functioning and intellectual abilities. The studies brought together flexible and adjustable individual and group interventions, highlighting verbal and creative expressions of drawing and writing [86, 82, 94, 84, 103, 87]. These strategies must be taken into account by mental health professionals in the child mourning process. The existence of these effective treatments offers a promising perspective for reducing the symptoms of complicated grief and transforming it into a normal grieving process, facilitating the reintegration of loss into the lives of children and adolescents. These interventions provide not only emotional support but also opportunities for expression, understanding and reconstruction of meanings around death, helping in the process of adaptation, resilience and sense of belonging. Brown et al. [104] add that, for children aged three to five years, play therapy and bibliotherapy should be considered; for children aged six to 12, opt for books and memories in images and through objects, as well as games; For teenagers aged 13 to 18, writing diaries and poetry appears to be an effective strategy. The authors stated that music therapy is useful for grieving children and adolescents to process, understand, feel, remember and integrate the experience of loss. Furthermore, the literature mentions that grief in children can include irritable behaviors, changes in conduct, poor school performance and difficulties in concentrating [105]. The study by Miles-Mason [84] highlighted these signs, proving that an integrative and appropriate treatment not only revealed improvements in grief symptoms but also in other altered aspects, including school performance, prosocial behavior and emotional wellbeing. This article offers a comprehensive view to mental health professionals about the effectiveness of constructivist-narrative strategies in children’s grief and subsequent modifications. The diversity of therapeutic methods allows for a range of options for professionals who work with grieving children and adolescents, allowing for more personalized and effective treatment, even if the primary focus is not complicated grief. The conclusions above highlight the importance of professional preparation to deal with grief in childhood and adolescence when individuals are undergoing physical and mental development.

Constructivist-Narrative Strategies are Effective

Narrative retelling and imaginary conversations are effective strategies for treating complicated grief. They are widely applied in various interventions, including cognitive-narrative therapy [106,22], meaning reconstruction approaches [77, 78, 81, 15, 22, 107], group therapies [86, 12, 108-112, 103,100, 88, 97, 89] They have several benefits: transforming painful memories into pleasurable ones and modifying feelings of guilt, shame and anger towards acceptance and integration of the loss [13, 112, 110] promote more complex and meaningful narratives about loss [75] reduce complicated grief symptoms such as persistent longing for the deceased and levels of sadness [89, 85] maintain a continuous bond with the loved one, facilitating the construction of new narratives with new meanings and positive memories [78, 80, 81, 15] and assist in carrying out satisfactory daily activities, developing a hopeful future and engaging in new interpersonal relationships [77, 107, 85]. Viewing photographs is a fundamental strategy in intervention for individuals with complicated grief, as it allows visual and verbal processing of the story of death, harmonizing self-efficacy and control in the new narrative [64, 96] address memories and feelings nostalgically and prolong the relationship with the deceased [14, 88]. These strategies offer a robust framework for healthcare professionals to address complicated grief, promoting acceptance of loss, construction of new meanings, and adaptation to a new reality with a restored identity.

Integrative Treatments are More Effective for Children, Adults and the Elderly

Grieving individuals are motivated by a psychological need to find meaning and purpose in their new lives without the deceased, requiring comprehensive adaptation on social, behavioral, psychological, and physiological levels [75]. Neimeyer [113] argues that cognitive-behavioral strategies must be complemented with constructivist-narrative strategies to promote healthy narratives and reconstruct meaning in cases of complicated grief. Integrative treatments were consolidated in the systematic literature review, consisting of cognitive-behavioral, interpersonal, constructivist-narrative and written therapy strategies. Studies have demonstrated the accessibility, versatility and effectiveness of interventions as capable of processing and expressing thoughts and emotions, finding meaning in loss, promoting adaptation to grief and the new reality, and reconstructing healthy narratives. In this way, we emphasize the contributions that integrative treatments can have for complicated grief in various populations, from children onwards [86, 82, 94, 84, 103, 87], adults [77-81, 12, 83, 14, 89] and elderly people [13, 109, 110, 88, 91], confirming Currier’s study. et al. [114], which points out more favorable results in the grieving process with psychological interventions compared to pharmacological approaches.

These nuances emphasize the importance of adapting therapy to the characteristics of individuals and highlight the variety of therapeutic approaches available to deal with complicated grief since everyone uniquely faces grief. Therapeutic inclusion allows considering the cognitive, behavioral, emotional, cultural and spiritual aspects of the grieving individual [84, 112, 115, 116]. This article demonstrates that the implementation of integrative treatments in various populations calls for the importance of sensitivity in clinical practice.

Therapeutic Writing is Effective as Individual Personalized Treatment as an Additional Complement

Interventions focused on therapeutic writing have demonstrated their effectiveness in reducing the symptoms of complicated grief, proving their importance and applicability both in individual personalized treatment and as an additional complement. It is an easy-to-implement and low-cost strategy, which offers a sense of control and autonomy to the client [16], allowing transformations in cognitive, emotional, social and biological dimensions [65]. The most common form of writing studied was letter writing: establishing correspondence with a loved one, saying goodbye to them and expressing real emotions and feelings [77, 79, Bryant et al. 2014, 82, Elinger et al. 2013,2015, 117]. This form of writing facilitated the exploration of the interpersonal relationship with the deceased, and like narrative retelling and imaginary conversation strategies, it promoted the creation of an ongoing relationship, generated comfort and expressed unresolved issues. In certain studies, writing was associated with photographs, poetry, images, drawings and oral expression. These constructivist-narrative strategies helped in the processing and reinterpretation of pleasurable emotions, in the sharing of suppressed feelings, in the reconstruction of the feeling of guilt, in the creation of meaning, and in addition propagating of personal growth and appreciation of life [90, 82, 16, 118] alludes to poetry as a form of writing that contains the writer’s emotions, thoughts, behaviors, sensations and desires, capable of representing a more complete and quality narrative, which exposes the most painful moments of life. Furthermore, writing is also linked to the re-authoring strategy of narrative therapy, as it reinforces positive aspects in the grieving individual’s new narrative, in contrast to the elements initially present in the dominant story [119]. It was also noted the relevance of health professionals using writing in therapy with instructions, given the best results achieved in integrating the experience of loss, promoting self-awareness and motivation for narrative change [120, 121]. Furthermore, the literature proves the usefulness of this strategy as a simple, practical and clinically relevant resource [16], as a method of communication for clients with verbal difficulties [120] and as a way of spontaneous expression [118]. However, mental health professionals are urged to observe clients and their cognitive and literacy skills, their comfort and their motivation in writing about aspects related to loss [16].

Online Treatment can also Demonstrate Effectiveness

Research has grouped a set of effective internet-based interventions for complicated grief, classifying them as lowthreshold, adaptable and acceptable for a range of populations grieving due to cancer [121], pregnancy loss [47, 122], suicide [101], loss of children [15] and other losses [17, 92, 117]. All studies demonstrated positive results in reducing symptoms of complicated grief and other psychological conditions such as depression, anxiety and posttraumatic stress. Online therapy has been shown to be as effective as in-person cognitive behavioral therapy approaches, even without the physical presence of the therapist. Furthermore, the continuity of observed benefits over time, even after treatment has ended, is admirable, proposing that internet-based interventions can have a lasting impact on the grieving process and mental health of individuals [98] These approaches highlight the accessibility and convenience of these types of interventions, so they should be considered when there are economic, mobility and demotivation barriers to face-toface treatment. These are therapies that meet the substantial requirements of a grieving individual: privacy, comfort, intimacy, shame, stigma and self-disclosure [17,18].

Group Narrative Therapy can Help Validate and Reconstruct Alternative Narratives

Treatment for complicated grief based on narrative therapy can be carried out individually or in a group. Group therapies for complicated grief have demonstrated significant results [86, 12, 108, 115, 103, 123, 109, 19] they can be effective in multiple contexts of loss and bring greater benefits such as co-construction of a feeling of belonging among those involved (sharing similar narratives without judgment), decreased isolation, increased social support in terms of offering and receiving it (expresses understanding of the ability to overcome and adjust to the context of loss), promoting moments of catharsis, personal development and realistic goals. That said, it is crucial to pay attention to these aspects and the profile of the grieving individual, recognizing the advantages of complementing it with individual and personalized treatment tailored to their needs and preferences [109]. Group Therapy for Complicated Grief applied in studies by Lacasta and Cruzado [108] [109-111, 124, 100, 88] complies with the principles of narrative therapy, particularly the presence of significant elements in the treatment, does justice to the consolidation phase, which involves external witnesses. Mental health professionals should reflect on the formulation of group therapies for complicated grief, as the fact that there are witnesses (group members) in the counting and retelling of the story of loss facilitates the validation and reconstruction of alternative narratives, as well as allowing the grieving individual the development of a sense of community, empowerment and personal agency [58].

Final Considerations

According to Larsen [16], a large part of the grieving population does not need psychological therapeutic interventions, complying with the normal grieving process. However, the author indicates that around 40% of individuals who have suffered a significant loss would benefit from psychosocial support.

Tertiary interventions [30] based on narrative therapy and composed of constructivist-narrative strategies have shown effectiveness in reducing symptoms of complicated grief, adapting to loss, integrating painful emotions and maintaining a continuous bond. Constructivist-narrative strategies prove to be adaptable, especially benefiting grieving women, children and adolescents. Specific interventions, such as play therapy for children and therapeutic writing for adolescents and adults, offer emotional support and help in the reconstruction of positive meanings. This article aims to contribute to the continuous improvement of the quality of care for individuals with complicated grief. [125- 129]Understanding and scientific knowledge of constructivistnarrative therapeutic strategies allows mental health professionals to critically evaluate the effectiveness of clinical practices and adjust their approaches based on research and Science. Clinical practice is enriched, and the grieving population receives personalized care adapted to their characteristics. It is also intended to encourage the scientific community to investigate complicated grief. Readers are invited to recognize the importance of narrative reconstruction in the grieving process and attributing meaning to the loss of a loved one as aspects that promote wellbeing [130-135].

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