Research Article

Narrative Therapy and Constructivist Perspective: An Integrative Review of Complicated Grief and Effective Therapeutic Contributions

Petra Santos: 0009-0005-8258-593¹ and Luísa Soares¹*: 0000-0002-5373-1320

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

Submission: July 30, 2024; Published: August 29, 2024

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

How to cite this article: Petra Santos: 0009-0005-8258-593 and Luísa Soares*: 0000-0002-5373-1320. Narrative Therapy and Constructivist Perspective: An Integrative Review of Complicated Grief and Effective Therapeutic Contributions. Psychol Behav Sci Int J. 2024; 22(2): 556082. DOI: 10.19080/PBSIJ.2024.22.556082

Abstract

This literature review highlights the constructivist perspective of grief, providing detailed and grounded research on the effectiveness of narrative therapy and its strategies in treating complicated grief. The aim is to explore the theoretical and conceptual aspects of normal grief and its transformation into complicated grief, address risk and protective factors, and examine constructivist-narrative therapeutic contributions, with greater effectiveness in treatment and emotional relief. Creative narrative strategies such as photography, films, art, writing and music favor expression and narrative reconstruction, helping to create new perspectives on the problems faced by the grieving individual. Therapeutic effectiveness was highlighted in the narrative process of organization, reconstruction of meaning, integration and adjustment to the grieving process through symbolic methods of telling, retelling, connecting, understanding and restructuring the relationship with the deceased, accepting the experience of death and achieving fulfillment-integrated mourning, formulating a new personal and social identity.

Keywords: Complicated grief; Narrative therapy; Integrative review; Effective therapy tools

Introduction

Grief is a universal and complex experience, influenced by cultural factors Fuchs [1], that accompanies the loss of a loved one. Over the years, interest in studying the grieving process has grown significantly due to its clinical and social relevance. The diversity of approaches and theoretical conceptualizations about the phenomenon has resulted in a vast literature that is important to explore. This literature review highlights the constructivist perspective of grief in its understanding, providing detailed and grounded research on the effectiveness of narrative therapy and its strategies in treating complicated grief. Narrative therapy and the constructivist perspective offer a broad view of the complexity of grief and potential paths to reconstruction and reframing. From the intersection between cognitive-behavioral, constructivist and narrative approaches, narrative therapy stands out for centralizing individual narratives in the reintegration process, which is crucial for the construction of meaning and reconstruction of identity after a significant loss. By highlighting these approaches to investigating complicated grief, the need to understand this normative experience, which can evolve pathologically, is highlighted. The main objective of this article is to provide a comprehensive theoretical framework on the contributions of narrative therapy and its constituents in complicated grief disorder. The aim is to explore the theoretical and conceptual aspects of normal grief and its transformation into complicated grief, address risk and protective factors, and examine constructivist-narrative therapeutic contributions, which demonstrate greater effectiveness in treatment and emotional relief.

Methodology

An integrative review with the aim of presenting existing contributions on the applicability of narrative and constructivist-narrative strategies in complicated grief. The literature search was carried out using key keywords relating to narrative therapy and complicated grief 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 search for studies was carried out in the following databases: Google Scholar, B-On, PubMed, Springer Link, Taylor and Francis, Web of Science and Science Direct, in two languages, Portuguese and English. The selection of studies was carried out between January 2024 and February 2024.

What is Normal Grief?

The death of a loved one is a universal and inevitable event, predisposing the grieving process, which is rich in memories and emotions. This process can be painful in emotional, social, behavioral, cognitive and physiological dimensions Arizmendi B, O’Connor M [2],Bui E[3], Marques M[4], Moreira F[5], Neimeyer R, Burke L, Mackay M, Stringer J[6] Silva C, Carreta P [7]. Grief requires adaptation to the loss and absence of the deceased, internal changes and reconstruction of the meaning of life and the world Arizmendi B, O’Connor M [2] Bui E[3],Moreira F[5], Shear K [8], Worden J [9]. It is not limited to a specific period, being idiosyncratic and variable Arizmendi B, O’Connor M [2], Moreira F[5], Shear K [8], Maercker A, Lalor J [10], Ramos V [11]. It is not necessarily a psychopathological disorder, often representing a healthy adaptive reaction called normal grief, which does not harm physical and mental wellbeing Carreta P [7], Shear M, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, et al. [12], Shear K, Bloom C [13].

Multidimensional Manifestations of Grief Symptoms

Normal grief triggers a variety of physical, emotional, cognitive, behavioral and social symptoms, generally considered normative in the first few months Arizmendi B, O’Connor M [2], Bui E[3], Shear K [8], Shear M, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, et al. [12], Barbosa A, Pina P, Tavares F, Neto I [14], Serra C, Pires D, Faria J, Pereira M, Ângelo R, et al. [15]. Physical symptoms include breathing problems, dry mouth, physical pain, sleep disturbances, muscle weakness, chest tightness, loss of appetite, hypersensitivity to noise, digestive problems, blurred vision, increased heart rate, immune system dysfunction, fatigue and nausea. On an emotional level, it is common to experience crying, sadness, depression, anhedonia, longing, loss of identity, emotional indifference, motivation, anxiety, anger, despair, guilt, self-censorship, denial, loneliness, and sometimes hallucinations. Relief and emancipation can occur as positive reactions. Cognitive problems include disbelief, confusion, persistent worries about the deceased, difficulties concentrating and short-term memory problems. Behavioral symptoms may involve constant searching for a loved one, changes in behavior and interruption of usual activities. Socially, grief can lead to isolation and loss of interest in interpersonal interactions Arizmendi B, O’Connor M [2], Bui E[3], Carreta P [7], Barbosa A, Pina P, Tavares F, Neto I [14], Serra C, Pires D, Faria J, Pereira M, Ângelo R, et al. [15].

Progression in the Grieving Process: From Pain to Acceptance

The grief healing process is indefinite, characterized by the ability to integrate the loss of the deceased into the new reality. It includes a more pleasurable emotional expression, reduced guilt, resumption of daily activities, establishment of interpersonal interactions and preservation of fond memories without associated physical and psychological suffering. These signs indicate a gradual reduction in the intensity of grief symptoms, as well as a greater acceptance of the loss and the ability to live in peace, regardless of the physical absence of the deceased. It involves the (re)construction of identity and autonomy, adaptation to new experiences and definition of new goals in order to keep the loved one present in life continuously Fuchs [1], Arizmendi B, O’Connor M [2], Bui E[3], Carreta P [7], Shear K, Bloom C [13], Prigerson H [16]. Although the grieving individual returns to their usual activity, it is common to experience moments of sadness, especially on sensitive and celebratory occasions Shear K [8]. Normal grief can be compared to a scale with initially high levels of suffering, which regress over time Arizmendi B, O’Connor M [2]. In this process of advances and retreats, there is a transition from normal to integrated grief, marked by continuous adaptation to the loss, a gradual decrease in psychological pain and the creation of a vital commitment Shear K, Ghesquiere A, Glickman K [17].

What is Complicated Grief?

When the grieving process is prolonged in frequency, severity and chronicity, emotions and feelings remain persistently intense and distressing Ramos V [11], Boelen P, Prigerson H [18], resulting in the complication of normal grief Eisma M [19], Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20]. According to Holland et al. [21], complicated grief is serious and disabling, being the extreme of the pathological dimension. It is characterized by reinforcement and prolongation of typical grief reactions and symptoms, from profound sadness to emotional and social incapacitation Shear K, Ghesquiere A, Glickman K [17], Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Holland M, Neimeyer R, Boelen P, Prigerson H [21], APA [22], Li J, Tendeiro J, Stroebe M [23], Prigerson H, Boelen P, Xu J, Smith K, Maciejewski P [24] Individuals with complicated grief have difficulty expressing emotions, diminish their sense of identity and isolate themselves from close relationships, and may present somatic and psychic pathological symptoms Carreta P [7], Shear K [8], Zisook S, Shear K [25]. The literature encompasses several terms to refer to the nonintegrative, 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 Arizmendi B, O’Connor M [2], Worden J [9], Lalor J [10], Ramos V [11], Barbosa A, Pina P, Tavares F, Neto I [14], Delalibera M, Coelho A, Barbosa A [26], Prigerson H, Kakarala S, Gang J, Maciejewski P[27], Waller A, Turon H, Mansfield E, Clark K, Hobden B, et al. [28]. This article will use the term ‘complicated grief’ to refer to grief disorder due to its greater prevalence and association in the literature Maercker A, Lalor J [10], Mauro C, Reynolds C, Maercker A, Skritskaya N, Simon N, Zisook S, et al. [29] Nakajima S [30], Simon N, Hoeppner S, Lubin R, Robinaugh D, Malgaroli M, et al.[31].

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 APA [22].

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 APA [22]. The International Classification of Diseases-11 (ICD-11) identifies the complicated grieving process as a prolonged grief disorder WHO[32], with criteria parallel to the DSM-V. It adds criteria related to persistent and generalized desire and longing for the loved one, guilt and self-blame, denial and confusion Shear K [8], Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Rosner R, Comtesse H, Vogel A, Doering B [33]. According to ICD-11, prolonged grief disorder is present six months after the loss Shear K [8], Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Holland M, Neimeyer R, Boelen P, Prigerson H [21], Rosner R, Comtesse H, Vogel A, Doering B [33]. To harmonize persistent complex grief disorder with prolonged grief disorder, a group of researchers met in June 2019 Prigerson H, Kakarala S, Gang J, Maciejewski P[27]and concluded that the revised version of the DSM-V integrates the disorder of prolonged mourning, with this diagnosis being approved in November 2020 Prigerson H, Boelen P, Xu J, Smith K, Maciejewski P [24], Prigerson H, Kakarala S, Gang J, Maciejewski P[27],APA[34]. The diagnostic criteria remain corresponding to previous versions Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Prigerson H, Boelen P, Xu J, Smith K, Maciejewski P [24], Prigerson H, Kakarala S, Gang J, Maciejewski P[27], Rosner R, Comtesse H, Vogel A, Doering B [33].

Differential Diagnosis of Complicated Grief Disorder: The differential diagnosis of complicated grief disorder involves careful distinction from other conditions such as major depressive disorder, posttraumatic stress disorder and separation anxiety disorder APA [22]. The etiology of grief disorder differs from major depressive disorder, as it is marked by a focus on loss and longing for the deceased, unlike major depressive disorder, which can include sadness and crying but not necessarily these characteristics APA [22]. In relation to posttraumatic stress disorder, both involve stressful and distressing events, as well as intrusive thoughts, avoidance, anger and emotional numbness. However, individuals with grief disorder generally do not experience flashbacks, fear, or nightmares associated with the traumatic event, as in posttraumatic stress disorder. The worry, anxiety and anguish of complicated grief disorder are linked to the longings and memories of the deceased Arizmendi B, O’Connor M [2], Maercker A, Lalor J [10], Arizmendi B, O’Connor M [2]. As for separation anxiety disorder, there are similarities with grief disorder in terms of separation characteristics. However, while the first refers to current figures, the second highlights the suffering faced with the loss of a loved one APA [22].

Risk Factors of the 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 Marques M[4], Silva C, Carreta P [7], Worden J [9], Burke L, Neimeyer R [35], Neimeyer R, Burke L [36]. According to Delalibera et al. [26] and Dyregrov et al. [37], complicated grief affects approximately 10 to 20% or 10 to 15% of the bereaved population. Arizmendi and O’Connor [2] indicate that it is less common than normal grief, affecting 7% of grieving individuals.

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 parent-child and spouse relationships Burke L, Neimeyer R [35], Bowlby J [38], Piper W, Ogrodniczuk J, Joyce A, Weideman R [44]. Relational factors such as degree of kinship, level of emotional attachment and proximity are identified as risky, especially in ambivalent, narcissistic and dependent relationships Worden J [9], Zisook S, Shear K [25], Neimeyer R, Burke L [36], Keesee N, Currier J, Neimeyer R[41] Alvis L, Zhang N, Sandler I, Kaplow J [45], Heeke C, Kampisiou C, Niemeyer H, Knaevelsrud C [46]. Marital dependency is highlighted as a significant risk factor for complicated grief Neimeyer R, Burke L [36], along with separation anxiety, childhood abuse or neglect, authoritarian or permissive parenting, and insecure, anxious, and avoidant attachment Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Burke L, Neimeyer R [35], Piper W, Ogrodniczuk J, Joyce A, Weideman R [44].

Nature and Circumstances of Death: Elements such as the cause of death and the state of the deceased’s body also have a profound impact on the grieving process. 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 Neimeyer et al. [6], Silva C, Carreta P [7], Worden J [9], Burke L, Neimeyer R [35], Neimeyer R, Burke L [36], Bowlby J [38]; (Penman et al., 2014; Wright et al., 2010).

Social and Temporal Context: The culture, historical context and religion of the grieving individual are social factors that contribute to the development of complicated grief, including precarious socioeconomic status, lack of recognition of death, lack of social and institutional support, unresolved family crises and isolation Worden J [9], Zisook S, Shear K [25], Burke L, Neimeyer R [35], Neimeyer R, Burke L [36]. Gana and K’ Delant [47] highlight another risk factor: the time since the loss. As time passed since the death of a loved one, the greater the persistence of pain and suffering, with a lack of feelings of relief.

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 Mason T, Tofthagen C, Buck H [48]. 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 selfconcept, 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 Worden J [9], APA [22], Zisook S, Shear K [25], Burke L, Neimeyer R [35], Neimeyer R, Burke L [36], Bowlby J [38], Garcia L, Júnior J [40], Piper W, Ogrodniczuk J, Joyce A, Weideman R [44], Heeke C, Kampisiou C, Niemeyer H, Knaevelsrud C[46], Mason T, Tofthagen C, Buck H [48]. Perspectives throughout different stages of the development of the life cycle. Studies on the relationship between age and the development of complicated grief prove the prevalence of this condition in elderly populations, especially between 75- and 85-years old Heeke C, Kampisiou C, Niemeyer H, Knaevelsrud C[46], Newson R, Boelen P, Hek K, Hofman A, Tiemier H [49]. Elderly widowers face more complicated marital grief compared to younger individuals, with psychological symptoms and necessary social and behavioral adjustments Supiano K, Luptak M [50]. The female gender, particularly women over 60, is identified as a risk factor Lobb E, Kristjanson L, Aoun S, Monterosso L, Halkett G, et al. [42]. From another perspective, studies by Mason et al. [48] and Rozalski et al. [51] mention that younger ages can represent a risk factor, while older ages can be named as a protective factor due to the likely life experience with a greater number of stressful and painful events.

Protective Factors in the Complicated Grief Process

The protective factors of complicated grief include social factors (stable social support), relational (secure attachment style), psychological (open communication about the loss, resilience, acceptance, low levels of neuroticism and adaptive functioning), circumstantial (natural death and less stigma) and spiritual Piper W, Ogrodniczuk J, Joyce A, Weideman R [44], Mason et al. [48]. The ability to attribute meaning to loss is crucial to preventing the symptoms of complicated grief and is related to greater subjective wellbeing and healthy immune functioning Neimeyer et al. [6], Neimeyer R, Burke L [36], Neimeyer R [52], Neimeyer R [53], Neimeyer R, Baldwin S, Gillies J [54]. Lima and Fortim [55] highlight writing as inherent in attributing spiritual meaning to loss. Writing can be a protective factor in complicated grief, allowing for deeper and more reflective expression of emotions and thoughts. It helps the individual make sense of their experience, promotes autonomy and responsibility, and serves as a continuous connection with the deceased, free from external judgments and expectations.

The Constructivist Perspective of Grief

In the study of grief, several theoretical approaches have been used to understand its complexity. Constructivism, widely applied in Psychology, suggests that knowledge is actively constructed by individuals instead of being passively acquired Bruner J [56]. From a constructivist perspective, grief is an individual, fluid and dynamic process of active construction of meanings and identity in response to the loss of a loved one. It implies a reconfiguration of the pre-existing meanings of grieving individuals, affecting their functioning, values, identity, interpersonal and spiritual dimensions Worden J [9], Neimeyer R [52], Brinkmann S [57], Holland J, Neimeyer R[58], Neimeyer R [59].

The Central Role of Narrative in Understanding Complicated Grief

The central contribution of constructivism to the study of grief is centered on narrative, which refers to individuals’ life stories and their interpretations and retellings. It is defined as a neurological, psychological and social process whose events are elaborated and organized around a specific theme and meaning Neimeyer R, Holland J, Currier J, Mehta T [60]. The death of a loved one challenges the individual’s identity, making the experience of grief an emotional transition that is difficult to integrate into reality, revoking the assumptions that guided their life story Neimeyer R, Holland J, Currier J, Mehta T [60]. In the context of mourning, narratives are crucial to integrate the loss, considering the personal, cultural and spiritual particularities that shape identity Neimeyer R [61]. A maladaptive integration can result in disorganization in the death narrative, triggering a prolonged process of searching for meaning and purpose in a reality marked by the absence of the deceased, manifesting complicated grief Neimeyer R [61]. To deal with grief healthily, individuals must attribute meaning to death, understand its causes, find hope, benefits and learning in the experience, and reorganize their identity according to the new reality Neimeyer R, Baldwin S, Gillies J [54].

Cognitive-Behavioral Foundations in the Constructivist View of Complicated Grief

The constructivist perspective is influenced by the Cognitive- Behavioral Theoretical Model of Boelen et al. [62], who identify three processes in the manifestation of complicated grief: failures in the integration of autobiographical memory, development of negative beliefs and symptoms, and the presence of avoidant, anxious and depressive strategies. Neimeyer [63] states that the integration of death into autobiographical memory occurs through narratives. When successful, the grieving individual constructs a coherent narrative favorable to their identity, leading them to socially valued actions. Constructivists take an exploratory and elaborative approach to dealing with negative beliefs and symptoms in individuals with complicated grief rather than emphasizing irrational or maladaptive beliefs, as highlighted by Boelen et al. [62,63]. Neimeyer [63] argues that cognitivebehavioral strategies must be complemented with constructivistnarrative strategies to promote healthy narratives and reconstruct meaning in cases of complicated grief.

Narrative Therapy

Historical and Theoretical Contextualization of Narrative Therapy

The narrative approach in Psychology, influenced by constructivism and social constructionism, emerged in the 1980s as one of the most preponderant contemporary psychotherapies Gonçalves Ó [64], Gonçalves M [65]. Michael White and David Epston, from Australia and New Zealand, stand out as pioneers. In Portugal, authors such as Óscar Gonçalves, Margarida Henriques, Miguel Gonçalves, João Batista, Luísa Soares, João Oliveira, Divo Faustino, Cátia Braga and Madalena Alarcão also contribute significantly to the narrative approach. Social constructionism emphasizes the importance of language in interpersonal interactions and the construction of meaning, accompanied by social and historical factors. It promotes a critical and reflective stance, arguing that meanings are recreated in language through negotiation and social sharing Gonçalves M[66]. Narrative therapy was inspired by the ideals of Bateson, Bruner, and Foucault White M, Epston D [67]. Bateson emphasized the importance of distinctions perceived by human beings for understanding the world Gonçalves M, Silva J [68]. Bruner highlighted two forms of thinking, paradigmatic and narrative, highlighting the active capacity of individuals to construct meaningful narratives about their realities Gonçalves Ó [64], Gonçalves M [65]. Foucault contributed to understanding subjectivity as a discursive, historical and social construction that shape identity Gonçalves M, Silva J [68].

Narrative therapy is an extension of cognitive-behavioral therapy based on a postmodern constructionist perspective, which contrasts with empiricism Gonçalves M, Silva J [68]. According to Gonçalves [64], it focuses on the narrative process, aiming to increase the coherence, complexity and multiplicity of the client’s discursive construction, promoting development, freedom and creativity. According to cognitive-constructivist perspectives and social constructionism, narrative therapy diverges from psychopathological, rational and deterministic paradigms Gonçalves M, Silva J [68], Gonçalves M, Santos A, Matos M, Mendes I, Martins C[69], Ricks L, Kitchens S, Goodrich T, Hancock E [70]. Instead, it embraces the complexity of human experience, adopting a de-constructivist, narrative and conversational stance, which considers problems as being socially and culturally constructed Gonçalves Ó [64], Gonçalves M [65].

Principles of Narrative Therapy

The key principle of narrative therapy is the ability of individuals to construct stories, to understand and attribute meaning to their lives White M, Epston D [67]. The complexity and diversity of a narrative reflect the richness of clustered meanings Gonçalves Ó [71]. Narratives are composed of concepts, symbols, metaphors, values, beliefs and objectives about the experience lived in a timeline and full of meaning. They enable individuals to reflect on their experiences and organize their reality, providing an internal structure for self-knowledge and understanding interpersonal relationships from the past to the future Moreira F[5], Gonçalves Ó [64], Gonçalves M [65]. The construction of a narrative is complex, involving three basic dimensions: life experiences, social context and time. These elements highlight the active role of individuals in creating meaning in their narratives. Narrative therapy aims to reconstruct meanings and experiences creatively through therapeutic dialogues, enabling individuals to co-construct new realities about themselves, making them protagonists of their stories Gonçalves Ó [64], White M, Epston D [67]. Problematic, totalitarian or problem-saturated narratives are rigid and dominant, preventing the development of coherent alternative interactions and narratives Moreira F[5], Gonçalves M, Silva J [68]. These narratives cause feelings of impotence, suffering, despair and uselessness Moreira F[5], White M, Epston D [67], Gonçalves M, Silva J [68], as well as limiting the individual’s cognitive, behavioral and affective activity, generating incoherence internally and the environment Gonçalves M, Ribeiro A [72]. The restriction on the diversity of meanings and cognitive flexibility makes it difficult to design alternative narratives, which can contribute to psychological maladjustment and psychopathology Gonçalves Ó [64]. Gonçalves [65] postulates that in narrative therapy, what is not narrated is forgotten; that is, unmentioned events do not contribute to the construction of reality, experience and identity.

Phases of Narrative Therapy

Narrative therapy is organized into three phases Epston D [67]: deconstruction, reconstruction, and consolidation. Deconstruction is based on the understanding that sociocultural contexts influence the structure of the problematic narrative Gonçalves Ó [64], Gonçalves M [65]. White (2007) claims that this phase involves the externalization of the problem, where empathy and attention to the client’s language are essential. The client will perceive the power of the problem, separate it from their identity and identify exceptions, facilitating the creation of a new narrative Gonçalves M, Silva J [68], White M [73]. In the reconstruction phase, the therapist addresses the values and norms of problematic narratives to promote alternative narratives and new strategies for coping with the problem, that is, deconstruction of the client’s cultural and relational internalizations to recreate meanings White M [73]. This phase continues the externalization of the problem, constructs new narratives and uses metaphors, achieving unique results White M, Epston D [67]. Unique results or moments of innovation Gonçalves M, Santos A, Matos M, Mendes I, Martins C[69] represent situations whose problems were not the center of the client’s life (with the exception of problematic narratives, White M[74], and their identification contributes to deconstructing the dominant narrative and creating a new one Gonçalves M, Silva J [68]. The role of the therapist is to help the client recognize and value these new experiences White M [74]. The aim is to create an alternative narrative in which the client’s “I” is more dominant than the problem. The consolidation phase strengthens the alternative narrative constructed in the previous phases, expanding it White M[73]. At this stage, narrative therapy highlights the importance of the presence of third parties in the therapeutic process, referring to them as external witnesses. The objective is to perpetuate reflections that amplify and validate the client’s identity socially and challenge the isolation and individualization caused by the problematic narrative White M, Epston D [67], White M[73]. The alternative narrative must be aligned with the client’s internal objectives, appreciating their identity and encouraging a proactive stance Gonçalves M, Silva J [68].

Main Narrative Therapy Strategies

In narrative therapy, it is essential to establish a collaborative and co-authored therapeutic relationship between therapist and client. The focus must be given to the client and their narratives, establishing them as their author and expert. The therapist must adopt an interpretative and active listening stance, demonstrating genuineness and interest Gonçalves M[66], White M[74]. The therapeutic process begins with the client’s story and its meaning, explored together in the prevailing context White M[74], Souza L, Lion C, Vidotto L, Moscheta M [75]. This collaborative strategy reveals a co-constructed session in which both evolve spontaneously, influenced by the emerging meanings in therapeutic dialogues White M[74]. Externalization is the intervention strategy that aims to separate the problem from the client’s identity (“the individual is not the problem, the problem is the problem”), dismantling saturated narratives and implementing new ways of understanding and coping White M[74], Souza L, Lion C, Vidotto L, Moscheta M [75]. White [73] describes four steps in externalizing language: negotiating a specific definition of the problem, mapping the effects of the problem on the client’s life, evaluating the effects of actions on the problem, justifying the assessment, allowing the client to make decisions, foster a new identity and separate themselves from the problem. The therapist questions the client about the impact of the problem on their relationships and areas of functioning, removing the intrinsic belief that the problem defines them White M[74]. This understanding promotes narrative change. The client begins to disengage from the problem while the therapist encourages the exploration of different views of the dominant story White M, Epston D [67]. Re-authoring develops more complex narratives, transmitting new thoughts, feelings and behaviors contrary to the problematic narrative White M[73]. This strategy values and reinforces the omitted parts of the client’s life story Souza L, Lion C, Vidotto L, Moscheta M [75].

Remembering reorganizes narratives, inserting new characters, moments, beliefs and values into the client’s alternative history and identity White M[73]. Therapeutic letters are also a valuable tool in narrative therapy, which helps to understand changes in therapy and the client’s life, from the modification of meanings to the creation of an alternative narrative. Therapeutic letters are future-oriented, emphasizing a hopeful and constructive vision White M, Epston D[67], Gonçalves M, Silva J [68]. They represent a powerful strategy for communication, motivation and improvement in interpersonal relationships, validating and consolidating the alternative narrative, reducing inconsistencies and enabling revisions when necessary White M, Epston D [67], Ricks L, Kitchens S, Goodrich T, Hancock E [70], Ferreira J, et.al. [76]. This tool uses the power of writing to enhance and generalize actions, reflections and meanings of the session, contributing to biopsychosocial wellbeing Ferreira J, et.al. [76].

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 Silva C, Carreta P [7], Neimeyer R, Holland J, Currier J, Mehta T [60], Azevedo D [77]. Waller et al. [28] classify psychological interventions in grief into three levels: primary, secondary and tertiary. Primary interventions are aimed at individuals experiencing normal grief; secondary interventions are for groups at higher risk of developing complicated grief; tertiary interventions focus on individuals who have symptoms of complicated grief Waller et al. [28]. The literature needs to demonstrate more effectiveness in primary interventions, showing better results in secondary and tertiary interventions Mason T, Tofthagen C, Buck H [48], Breen L, O’Connor M [78]. This topic focuses on tertiary intervention, focusing on narrative therapy, which is relevant in complicated grief, especially difficulties in adapting to loss and 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 Moreira F[5]. 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 White M [73].

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 Shardlow J [79]. Narrative therapy can transform these narratives, 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, Fernández- Navarro P, et al. [80]. The elaboration of a new narrative during mourning allows the individual to face the loss comprehensively and adjust to reality without the deceased White M, Epston D[67], Peri T, Hasson-Ohayon I, Garber S, Tuval-Mashiach R, Boelen P [81]. Neimeyer [59] highlights the relevance of promoting the reconstruction of meaning rather than focusing on reducing symptoms, as this enables the grieving individual to develop self-efficacy and hope in relation to the future. Narratives allow grieving individuals to reevaluate their social position, facilitating adaptation to the loss. Retelling the story of death enables a restructuring of self-image and relationship with the world. This process generates multiple versions of the story, whose positive impact occurs when the narrator acts in line with the expressed content Gonçalves M [66]. It is hoped that by retelling their story, the grieving individual works through their loss and recognizes that it does not define their identity Moreira F[5].

Neimeyer [52] observed that it is common for grieving individuals to center the deceased in their lives, mixing positive memories and difficulty moving forward. Narrative therapy helps manage these emotions and promote healthy adaptations. A key objective is to redefine the relationship with the deceased, as a symbolic presence in the new narrative Ramos V[11], Neimeyer [52]. Consequently, the grieving individual experiences emotional relief, adapts to the new reality and builds an identity in accordance with the reconstructed narrative, which projects into the future and paves the way for new roles, habits and relationships Azevedo D [77]. Another objective is to create metaphors that give meaning to the experience of loss, emphasizing difficult aspects for the grieving individual Rocha J, Gabriel S [82]. The core of narrative therapy in complicated grief is the attribution of meaning, which is fundamental for the grieving individual to face the loss and reconstruct their reality Moreira F[5]. Narrative therapy organizes and restructures the death experience, allowing the grieving individual to remember the loss in a healthy and symbolic way, express feelings and keep the memory of the deceased alive in a meaningful way Lima and Fortim [55].

Constructivist-Innovative Narrative Strategies in Complicated Grief

Postmodern approaches use creative strategies to facilitate identification and reflection on feelings related to death, promote insights and reconstruct life stories and relationships with the deceased Silva C, Carreta P [7] . Neimeyer [52] highlights the importance of metaphorical, poetic and narrative strategies, which go beyond direct verbalization, especially in cases of complicated grief. Ricks et al. [70] 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. The strategies are grouped into expressive arts and therapeutic writing.

Expression through Art: In the context of expressive arts, different forms of therapy are used Ricks L, Kitchens S, Goodrich T, Hancock E [70]:

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 crucial in Psychology, allowing reflection, emotional expression and meaning. It helps individuals explore identity, narrate meaningful moments, and contextualize life experiences in a deeper and more eloquent way. It is important to differentiate between expressive writing and therapeutic writing. The first is used by researchers to study the benefits of emotional expression, while the second emphasizes writing exercises complementary to therapy Kerner E, Fitzpatrick M [83]. In this article, we chose to use the term therapeutic writing, encompassing both definitions. Writing is an effective therapeutic intervention in health and well-being, as it helps with psychological suffering and promotes positive effects Moreira C [84]. James Pennebaker was responsible for implementing this tool, when developing the expressive writing paradigm Pennebaker J [85]. 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 Carneiro R [86], Dolev-Amit T, Rubin A, Zilcha-Mano S [87], Glass O, Dreusicke M, Evans J, Bechard E, Wolever R[88], Robertson S, Short S, Sawyer L, Sweazy S [89]. 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 White M [73]. It is a crucial reflective strategy, offering therapeutic effects and a personal experience free from external criticism and judgment, without grammatical, syntactic or content restrictions. It can be used alone or as a complement to therapy, addressing individual variables such as cognition and emotion Figueiras M, Marcelino D [90].

Therapeutic writing facilitates the organization and integration of traumatic experiences, promoting changes in the coherence of the story Figueiras M, Marcelino D [90], Pennebaker J, Seagal J [91]. Writing about traumatic events helps clients identify and accept their emotions, leading to greater emotional control and ability to cope with painful experiences [85]. Lima and Fortim [55] highlight the importance of writing in preserving the memory of the deceased. Paiva and Rasera [92] and Ricks et al. [70] also highlight that writing increases clients’ awareness of their distressing experiences, offering a deeper internal understanding. Larsen [93] 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 [6,53]. However, it may initially evoke pain, especially when remembering traumatic aspects of the death Pennebaker J, Seagal J [91]. However, Pennebaker [94] 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

Neimeyer [53] and Neimeyer et al. [6] describe ideal constructivist-narrative strategies in the treatment of complicated grief, namely, narrative retelling, therapeutic writing, imaginary conversations and metaphors. 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 Neimeyer [53]. 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 Neimeyer [53]. Implemented progressively throughout treatment, it aims to reduce anguish, promote the extinction of avoidance mechanisms and explore meanings, contributing to the development of resilience Neimeyer et al. [6], Neimeyer [53] and the integration of the experience of death Ramos V [11]. When using narrative retelling, therapists must recognize that the reactions of grieving individuals may vary and that the process is gradual, initially risking increasing distress before perpetuating noticeable improvements Barbosa A, Pina P, Tavares F, Neto I [14]. 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 Neimeyer [53]. The integration of narrative therapy with metaphors facilitates the expression of stories about the death of a loved one, as they are significant symbolic representations of a specific experience or culture Paschoal V [95]. 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 [73] defends its applicability in mourning, directing attention to neglected aspects of life in addition to the loss that dominates the narrative.

Discussion and Conclusion

Complicated grief is considered a clinical disorder, different from normal grief, given the subjective experiences, intensity, duration and impairment of the individual’s physical and mental health, at a cognitive, emotional, behavioral, social and physical level Eisma M [19], APA [22], Garcia L, Júnior J [40] It perpetuates a repetitive cycle, with severe and disabling responses to loss, whose symptoms of intrusion, longing and longing for the loved one are at the center of life Maercker A, Lalor J [10], Prigerson H, Horowitz M, Jacobs S, Parkes C, Aslan M, et al. [20], Prigerson H, Boelen P, Xu J, Smith K, Maciejewski P [24], affecting considerable populations in around the world Arizmendi and O’Connor[2], Delalibera et al. [26], Dyregrov et al. [37], Djelantik A, Smid G, Mroz A, Kleber R, Boelen P [96], Rheingold AA, Williams JL, Bottomley JS[97], Yuan M, Liu J, Zhong B [98]. The literature on complicated grief is made up of a variety of similar terms. Their definitions may overlap or diverge, depending on the context and authors. Complicated grief, as previously described, refers to a grief reaction that significantly interferes with the individual’s daily functioning due to persistent difficulty in accepting the loss, emotional intensity, and inability to continue with daily activities Silva C, Carreta P [7], Shear K [8], Prigerson H, Boelen P, Xu J, Smith K, Maciejewski P [24]. 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), Shear K [8], APA [22], Rosner R, Comtesse H, Vogel A, Doering B [33]; Given the similarities above between the concepts and the greater frequency in studies Maercker A, Lalor J [10], Mauro C, Reynolds C, Maercker A, Skritskaya N, Simon N, Zisook S, et al. [29] Nakajima S [30], Simon N, Hoeppner S, Lubin R, Robinaugh D, Malgaroli M, et al.[31], Linde K, Tremi J, Steinig J, Nagi M, Kresting A [99], the present systematic review was limited to using the term ‘complicated grief’. Grief is a personalized and multifactorial process strongly influenced by the sociocultural context.

The relationships maintained with the deceased Silva C, Carreta P [7], Garcia L, Júnior J [40], Piper W, Ogrodniczuk J, Joyce A, Weideman R [44], the circumstances of the death Silva C, Carreta P [7], Neimeyer R, Burke L [36], the cultural and religious aspects Zisook S, Shear K[25], Neimeyer R, Burke L [36] and the socioeconomic, psychological, psychosocial, physiological and physical characteristics of the grieving individual Mason T, Tofthagen C, Buck H [48]play a crucial role in the development of complicated grief. Narratives include a framework of the experience lived by the individual and by those involved socially and culturally; therefore, constructivist-narrative approaches emphasize the need to consider several factors in the construction of alternative narratives, highlighting how the problem affects several important areas of the client’s functioning Souza L, Lion C, Vidotto L, Moscheta M [75]. According to White and Epston [67], psychological suffering is related to the creation and maintenance of problematic narratives. The loss of a loved one alters the sense of meaning and identity, producing a dominant narrative whose painful thoughts and emotions are placed with emphasis on a parallel temporal reality Shardlow J [79], Alves D, et al.[100], Rafaely M, Goldberg R [102]. According to Gonçalves [64,71], narrative therapy is a treatment of social constructionism, open, creative and co-constructed between therapist and client, which allows understanding of the meanings implemented in the problematic story. Together with constructivist-narrative strategies, they are crucial approaches in the development of adaptive and integrative narratives, highlighting their richness in the autonomous construction of new realities and distinct meanings Rafaely M, Goldberg R [102], Rheingold A , et al.[103]. Narrative therapy captures the skills and experiences of the grieving individual, co-constructing a new identity in which the loss is externalized Peri T, Hasson-Ohayon I, Garber S, Tuval- Mashiach R, Boelen P [81], Rafaely M, Goldberg R [102]. The process of reconstructing meaning is seen as an integral and crucial part of the integrated grieving process Neimeyer R [53], which implies knowledge of the consequences, benefits and learning of the experience, given the identity inserted in the new reality Neimeyer R, Baldwin S, Gillies J [54].

The transformation of a problematic narrative into a coherent and functional narrative, through the attribution of meaning, enhances the personal and interpersonal development of the grieving individual Peri T, Hasson-Ohayon I, Garber S, Tuval- Mashiach R, Boelen P [81], Rafaely M, Goldberg R [102] and is associated with wellbeing subjective Neimeyer R, Burke L [36], Neimeyer R [53]. This process can make the person feel capable of experiencing healthy grief without the physical presence of the deceased Neimeyer R, Burke L, Mackay M, Stringer J [6], White M, Epston D [67], Peri T, Hasson-Ohayon I, Garber S, Tuval-Mashiach R, Boelen P [81]. This narrative change is achieved through the three phases of narrative therapy (deconstruction, reconstruction and consolidation, White M, Epston D [67] and the discovery of unique results or moments of innovation, given that the client has been able to think, feel and act in a different way from the pattern of the problematic narrative Gonçalves M, Santos A, Matos M, Mendes I, Martins C [69], that is, he debated the dominant pattern, separated his identity from the loss of the deceased, restructured his life story and achieved meanings and purposes Gonçalves M, Silva J [68], Gonçalves M, Santos A, Matos M, Mendes I, Martins C [69], Fernández-Navarro P, et al. [80]; However, it is pertinent to recognize the difficulty of narrative reconstruction, as the grieving individual must allow themselves to say goodbye and continue with their life and new reality Alves D, et al.[104]. Narrative therapy strategies and creative interventions demonstrate benefits in complicated grief, facilitating emotional expression and consequent reconstruction of the bond, not only verbally but also visually and in writing Rafaely M, Goldberg R [102], Rynearson E [105]. Constructivist-narrative strategies, such as expressive arts and therapeutic writing, enrich the therapeutic materials available for treating complicated grief. Photographs, films, music, narrative retellings and imaginary conversations allow for a deep and multifaceted exploration of the emotions, relationships and experiences related to grief. In particular, therapeutic writing stands out for its ability to organize and integrate traumatic experiences, contributing significantly to the relief of psychological suffering and the promotion of long-term wellbeing Ricks L, Kitchens S, Goodrich T, Hancock E [70], Neimeyer R [53]. Through the contributions of narrative therapy, grieving individuals can reflect on the past and their relationship with their loved ones, achieve a metacognitive and emotional understanding of what they are feeling in the present, and work towards a hopeful future perspective. The alternative narrative enables the increase of skills. It is built based on the life experiences, social context, language and time of the grieving individual, enabling them to be the protagonist of their story Gonçalves Ó [64], Gonçalves M [65], Epston D [67]

Final Considerations

The main objective of this article was to investigate the contributions of narrative therapy in the process of complicated grief, presenting a set of constructivist-narrative strategies useful for its treatment. The ability of narrative therapy to transform problematic narratives and promote the co-authorship of new stories highlights its relevance in the complicated grieving process. Therapeutic effectiveness was highlighted in the organization, reconstruction of meaning, integration and adjustment to the grieving process through symbolic methods of telling, retelling, connecting, understanding and restructuring the relationship with the deceased, accepting the experience of death and achieving fulfillment-integrated mourning, formulating a new personal and social identity. Narratives are essential tools for therapeutic interventions, allowing access to clients’ subjective experiences, their relationships and metaphorically attributed meanings Fuchs T [1]. These mechanisms of change allow the benefits of loss to be found, the reduction of anguish, longing, intense emotional pain and worry, the development of positive memories and a greater interest in daily life, recognizing that grief, from a constructivist perspective, is an active process of reaffirmation and reorganization of identity Silva C, Carreta P [7], Neimeyer R [61], Jones S, Martini M [106].

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