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Aging & Mental Health
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Randomised controlled trial of a cognitive narrative
intervention for complicated grief in widowhood
a a a
Virginia Barbosa , Mónica Sá & José Carlos Rocha
a
ISCS-N, CESPU, CICS - UnIPSa, Gandra, Portugal
Published online: 30 Sep 2013.

To cite this article: Virginia Barbosa, Mónica Sá & José Carlos Rocha (2014) Randomised controlled trial of a
cognitive narrative intervention for complicated grief in widowhood, Aging & Mental Health, 18:3, 354-362, DOI:
10.1080/13607863.2013.833164

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CG is more prolonged and severe than expected Keijser. Knaevelsrud. Hansson. De Jaegere. many researchers believe that CG Willcock. (2011) reported that in a sam. Spousal bereavement is the MDD and/or PTSD. despite this. tive way. Lobb. 2007). outpatients have both CG and MDD. We discuss healthy grief or uncompli. jose. 2007. As a result. Portugal (Received 7 April 2013. 4. 2007. Nikoletti. Zuckoff et al. & Schut. Newson et al. Castro & Rocha. Taking (Golden & Dalgleish. 2006). 2001). Folkman. Schut. 3. BDI and IES-R reflect the effectiveness of the intervention along the longitudinal profile. complicated grief Grief is a well-marked event with powerful meaning in indi.. 1998.cespu. intrusive thoughts. Email: monica. Wittouck. Loh. Conclusions: These results reinforce the importance of brief interventions that combine a reduced number of sessions with lower costs. de Keijser. However. 2006).pt Ó 2013 Taylor & Francis . Kato & Mann. 2000.6% have both CG Portzky. Hosman. Newson. Jenkins.. depressive and traumatic symptoms compared to the controls. 2001. 2010.UnIPSa. and its effectiveness has been contro- versial. 2011. & van den approximately 40% of the general population meet the crite- Bout. & van Heeringen. therefore. Gandra. & et al. they display symptoms that meet However. Stroebe et al. during a mourning process. that in addition to CG. to the level of functioning prior to the loss (Newson et al.. & ability to function in everyday life is regained (Boelen & Monterosso. cognitive narrative intervention. Stroebe. Simon et al. affects the individual’s functional capacity (Tomita PTSD. & Prigerson. No. The aim of this study is to evaluate the effectiveness of a cognitive narrative intervention for complicated grief (CG) for controlling post-traumatic and depressive issues. CESPU. 2007. Prigerson et al. Wittouck et al. Bonanno. 2003.2013. loss of interest. sented with MDD symptoms. such as MDD (Zisook.alison. 2002.rocha@iscsn. and Prigerson (2004) reported that vidual lives (Boelen. and 69% show triple co-morbidity. the criteria of other disorders as well. Method: The study is a randomised controlled trial and uses the Socio Demographic Questionnaire (SDQ). widowhood. Kristjanson.com. 1995b).sa@gmail. Silva (2010) concluded that 70.38 to 4. (2007) found (Bonanno et al. Hek. emotional and cognitive subjectivation. such as sadness. intervention in this area is type of loss that most often results in psychological and psy. Wagner. ple of elderly patients. et al. & Judd. clinically relevant and should at a minimum address this tri- chiatric referral and leadings to severe and prolonged feel. 1994) or PTSD (Schut.. the process is referred to as complicated grief Shuchter. 354–362. & ria for CG and not for MDD or PTSD. Monica Sa* and Jose Carlos Rocha* ISCS-N. when this process is not experienced in a norma.8% had CG.833164 RESEARCH ARTICLE Randomised controlled trial of a cognitive narrative intervention for complicated grief in widowhood Virginia Barbosa. 1999) that are validated presents a 2. bereaved elders with CG are likely to meet the criteria for 2011. & Tiemeier. Jane-Llopis.9% of psychiatric & Kitamura. the Beck Depression Inventory (BDI) and the Impact of Events Scale-Revised (IES-R). Van Autreve. Prigerson developed yet (O’Connor. Hofman.org/10. 1995b). Cruess. Mazure. van den Hout. many people cated grief when the loss turns out to be accepted and the experience various symptoms (Kristjanson. 1991). It has been (95% CI 1. the use of narratives has demonstrated *Corresponding authors.. The loss of a spouse Kang & Yoo.. this into account. & Stroebe. Sledge. accepted 5 August 2013) Objective: The implementation of bereavement interventions is frequently requested. 2006.42-fold increased risk of experiencing CG and acceptable for patients (Mu~noz.1080/13607863. metaphorisation and projecting. Aoun. There were three phases in the study: (1) The SDQ and CG evaluations were applied to bereaved elders (n ¼ 82). Prigerson fit from short-term interventions (Jane-Llopis & Barry. http://dx. CICS . the Inventory of Complicated Grief (ICG). 2005. On the other hand. & Anderson. The bereaved elders with the 40 highest ICG values (25) were randomly allocated into two groups: the intervention group (n ¼ 20) and Downloaded by [University of Liverpool] at 17:16 07 October 2014 control group (n ¼ 20). 73.. 2012. 2014 Vol. BDI and IES-R assessments were repeated. (3) Two months later. and prevents their return and PTSD. CG is not yet included in stated that the best treatment for CG may have not been the DSM-4 (Jacobs.21). Results: Outcome measures showed a statistically significant reduction of CG. 18. and 49% met the criteria for 2007). Very high effect sizes for the ICG. in addition to CG. 2011) and that there is no is a diagnostic entity that is distinct from major depressive well-defined protocol for psychological interventions in this disorder (MDD) and posttraumatic stress disorder (PTSD) area (Stroebe.doi. 2006). Paulus. Maercker. Aging & Mental Health. the ICG. (2) participants were evaluated using the BDI and IES-R and the IG gave informed consent to participate in an intervention with four weekly 60-min sessions addressing recall. de (CG). 2003. thus. Bout. Lichtenthal. Clisnicians would bene- ings of grief and loneliness (Parkes. which is reflected in an increased adherence to the programme along with high effectiveness. Keywords: randomised trial. and van den Bout. 2011). 55% of complicated grievers pre- Boelen. ple group of co-morbid symptoms. 1999). & Dijkhuis. 2008.. 2006).

ous session. Parkes. presence of Glaser. 2013). The The current study. silence and reflection of meaning. Interventions for CG informed consent was requested from eligible using narrative procedures of meaning-making. ual (Jane-Llopis & Barry. sharing memories. Forty of these. Repeated from a specific episode related to the loss. There are three sequential phases: ond step was the exploration of the cognitive components. Sousa. (Neimeyer. metaphorisation. has therapeutic effects (Pennebaker. 2006). & Berman. Nezu & Nezu. This can be discussed as follows ‘Does this narrative criteria were eligible. cognitive narrative therapy (CNT). 2002a). were used. what would the intervention group began a programme based on you think he would say?’ Finally. 2004) would enable the construction of robustness of the treatment based on an intervention man- Downloaded by [University of Liverpool] at 17:16 07 October 2014 a better-adapted bereavement narrative. performed in Portugal. such as para- into either the intervention group (n ¼ 20) or the waiting phrasing. (2) Participants (N ¼ 40) were then niques eliciting metaphors from the perspective of another. aimed to manual should be descriptive and allow the investigator to evaluate the effectiveness of cognitive narrative interven. Intervention Frank. choose a metaphor/title unifier. projecting new goals and writing. A therapy or psychotropic medication use were excluded. 2008). consistent with the methodology of CNT. make adjustments. narrative can also be seen as an adapted instrument for the Forty eligible participants were selected for this study. Our attention focuses on the Manual of tion in reducing the total values of complicated grief. complicated grief in widowhood Careful use of sensorial memories with patients at risk To achieve our objective. ‘If it was a Sousa. & Rocha. 2005) and thoughts substance abuse or dependence. the objective of this session was to Method evoke the most significant episode of loss and to make Trial design clear the meaning of the deceased.34). It was necessary to shorten the number pants by examining differences between two groups: the of sessions due to time constraints. including robustness tests of intervention and sion addressed emotional and cognitive subjectivation. two months projecting took place. the expression with apparent or previously reported problems related to of emotions (Stroebe. also to explore and evaluate their meaning. 2005. to explore different meanings for the chosen episode and to considering the cut-off value for this instrument (Frade. (3) Finally. Pacheco. meaningful future projecting narratives. Initially. BDI and IES-R on members of both groups. just as participants. bias control (Nezu & Nezu. have shown to be effective and of therapeutic value (Lichtenthal & Cruess. providing an alternative to the root meta- in northern Portugal. and those participants in For example. while still remaining IG (intervention group) and controls (control group. Aging & Mental Health 355 positive results in interventions with the bereaved (Currier. it is important to consider the for PTSD (Rocha. Kiecolt-Glaser. Prigerson et al. with. The programme out intervention. and they were then asked to evoke memories longitudinal randomised controlled clinical trial. is a life together. & Rocha. emotions were activated. in which the objective was for the patient with the highest ICG levels (equal to or greater than 25. 1994. assessed with the BDI and IES-R.10. Schut. Those who fulfilled the inclusion phor. The metaphors created in the projecting phase had Participants the purpose to generate a more positive envisioning of the Bereaved elders were recruited from three nursing homes circumstances. & severe depression with a risk of suicide. severe hearing difficulties. The study was disclosed in detail and 2001. & Reynolds. used not only to refer to events. 2010. and (b) cognitive narrative intervention (inde. ‘If your husband/wife was here. Individuals Neimeyer. in contrast with the previ- variables). For example. 2008. 1995a). Houck. as well as tech- list group (n ¼ 20). The third session involved for the sociodemographic questionnaire. task of making sense. 2010). but with age varying between 65 and 92 years (M ¼ 80. The Patients described the episode and structured their experi- variables considered are the following: (a) complicated ence with sense of authorship. or current psycho- meaning reconstruction (Gonçalves. 2002b). what title would you give?’ Frequent use consented to participate and have been randomly allocated of specific interview skills was suggested. Sa. 1988). 2008).. The therapist invited the patients to build up and reconstruct several nar- ratives. the patients built and experimented after the intervention. retelling the story of the death. Patients described the importance of the deceased and their journey through This study. These findings also sug- gest that complicated grief is a specific condition in need of Manualised cognitive narrative programme for a specific treatment (Lichtenthal & Cruess. spousal loss over six months ago represent a more adaptive functioning?’ . waiting list). 2005). during the fourth session. we repeated the evaluation with the with other possible organisations of the episode. 2010. approved by an institutional review board. and the creative use of metaphors promotes dementia. and the sec- pendent variable). (1) assessment of the total value of the Inventory of followed by the realisation of associations between Complicated Grief of bereaved elders and data collection thoughts and emotions. was reduced to four individual weekly sessions lasting approximately 60 min each. The first session involved recalling narratives. generating ICG. (Gonçalves. psychotic symptoms. SD ¼ 7. and age over 60 years were the criteria. The second ses- measures. & Stroebe. movie or a book. cognitive narrative psychotherapy: manual of brief therapy depressive and traumatic symptoms in bereaved partici. coherence and diversity of grief. Shear. depressive and traumatic symptoms (dependent cognitive and emotional content.

a 19-item measure Statistical methods of CG (Frade et al. (2) After evaluating the instruments’ cut-off values and ity of the intervention by the IG. . Thirteen of the 53 cases displayed border. The ICG. Table 1 describes participant characteristics for resulting from activation of sensory experiences with each group. as well as for each patient. Afonso. We used the IBM SPSS Statistics soft- IES-R. a non-parametric chi-square test was used to compare frequencies and prev- alence between groups. variable was analysed and compared between groups at ties in terms of reliability (Cronbach’s Alpha: ICG. attrition of one participant in the IG due to his own death. . (c) end of each session. the IG and control group and (in the case of the IG) to contextualize the loss. These data were utilised to and there is no bias related to missing cases in either screen eligibility criteria.91. we also applied a multivariate general lin- administered the Inventory of Complicated Grief. issues with session scheduling did not arise. patient’s acceptability with the intervention programme. Cases ear model (GLM) of repeated measures for CG. and (d) number of participants who completed were monitored by supervisors to ensure that the therapist the last evaluation (n ¼ 19) (see Figure 1). Barbosa et al. and the and confidentiality. institutions. There were no signifi- cant differences between groups in all characteristics. At the beginning of each session. Therapy sessions were monitored. none of A brief SDQ was delivered to collect data from the the cases had been lost at the final evaluation (see bereaved elders. 2010). 1973).94). completion of the selection process. control homogeneity between group. session. names were replaced with numbers to protect anonymity sive symptoms (Vaz Serra & Pio Abreu. Regarding the Outcome measures controls. sociodemographic characteristics. & Rocha. 2004). tionship and contextualisation of the loss from the however. order to undertake an analysis of evolution over the longi- pants had CG. 356 V. bereaved’s perspective. Analysis of attrition rates in the sample sion in CNT. a summary of the Randomisation previous meeting was presented. The dependent variables were operationalised with three measurement instruments in their Portuguese versions: the ICG. who had undergone training and continued supervi. lated the effect sizes of the intervention. Both groups’ partici- phase described in CNT manuals was not performed due pants underwent the same sampling and assessment proce- to increased risk of traumatic recall (Rocha. we calcu- were administered at pre-treatment and again at a two. calculator. each It is important to note that the sensorial objectivation with 20 participants (see Figure 1). Twenty-nine did not sive and traumatic symptoms. tudinal profile (the influence of time factors and the inter- line symptoms of CG. 2002a. Gl oria. . The treatment was manualised and described The values of attrition rates for IG considered were the in a detailed session-by-session protocol to increase treat. the psy- Downloaded by [University of Liverpool] at 17:16 07 October 2014 number of participants who completed the intervention chologist conducted a self-assessment. there is a clear indication of good acceptability. this included information regarding Figure 1). Given that all of the research was conducted in personal identification. depres- with higher scores were flagged.89. participants’ groups of statements reflecting the severity of depres. were homogenous in that they displayed similarities in 2002b). Vieira. flagging those cases with a decrease in symptoms (better evolution) on the longitudinal profile. (1) Each dependent These instruments have adequate psychometric proper. a history of the couple’s rela. and they were excluded as a result. This was performed in have CG. first assessment phase (T1) and at the second assessment BDI. (3) With the consideration that the Sample size previous effect–size analysis only includes between- A total of 82 bereaved elderly were eligible and were groups effects. Four steps were followed. the BDI. which has 21 Before proceeding to the data analysis. 53 partici. at the number of participants in the intervention (n ¼ 20). dures. Some sessions (n ¼ 20). a conservative procedure adjusted to the number of cases. a 22-item measure of traumatic symptomatology ware (version 19) for statistical analysis and effect size (Castanheira. using the Hedges month follow-up. groups: an intervention group and a control group. the BDI and the IES-R phase (T2) using t test analysis. IES-R. brief questionnaire was used to evaluate the acceptabil. Thus. 2006). following: (a) number of initial participants (n ¼ 20). 1994. of the 20 participants initially contacted.. Subsequently. and they were also excluded. Therapists and treatment reliability Treatments were conducted by the first author of this work. there was no abandonment during the four sessions of the intervention programme or the subsequent evalua- tion (adhesion ¼ 95%. . there was an exploration and summarisation of These participants were randomly allocated into two the patients’ reactions. (b) ment reliability. In addition to these instruments. There was adhered to the protocol. sug- gesting that randomisation was successful. we presented the descriptive values of the chosen (see Figure 1). Upon actions (time  groups) in the intervention programme. and at the end of each The selected sample contained 40 participants (N ¼ 40). attrition rate ¼ 5%). 40 participants were (4) Finally. The participants in the IG and control group intense traumatic emotions (Gonçalves.

At T1 for the IES-R. at T2. SD ¼ 7. As seen in Table 2. using a repeated meas- for independent groups. there is a significant difference between groups for complicated grief (p < . there should (M ¼ 42. at T1. tive programme’s second evaluation control intervention significant differences between groups.45) compared to the controls cant differences between groups. in T2. can be compared when addressing the effectiveness of an with a significance level of p < . SD ¼ 7. The IG had a lower mean (M ¼ 25. line assessment.31). Among Regarding the effect size analysis of the cognitive narra- the baseline BDI scores (see Table 2). how- Comparison between IG and controls outcomes in the ever. Flow of participants through each stage of experiment. at the base- ures analysis. The IG had a lower intervention. SD ¼ 5. this statistical procedure did not suffi- We calculated the mean of the ICG. we can say that the value of the ICG.80. which is expected.32. there is no significant difference between groups on the ICG.80. nevertheless. we observed There are two essential conditions with which outcomes a very positive difference in traumatic stress outcome. we noted non. line.73). the . SD ¼ 6.01). 2002). there are very significant differences between the first and second phases groups. at T2. However. there should not be statistically signifi- mean (M ¼ 15. BDI and IES-R scores ciently clarify the intervention effects on traumatic stress. Aging & Mental Health 357 Downloaded by [University of Liverpool] at 17:16 07 October 2014 Figure 1. while at T2. (see Table 2).01. Results considering the randomisation procedures. at T1 and T2 and compared the differences using the t test this issue will be addressed later. we found a significant differ- ence between the groups. Due to problems with the base- be significant differences between groups (APA.46) when Effect sizes compared to the controls (M ¼ 39.

05.18 Importance of the deceased 9.00 we used the chi-square test implemented using the cross. we found that at a.s BDI T2 12. We found a positive five participants maintaining CG.53 2.29. continuous or categorical. As seen in Table 3. they represented 26.34 21.90 7.65 7. p < .7%) is evident. Intervention group Control group Characteristics n % M SD n % M SD p Sex .33 Other losses 12 60 15 75 . With traumatic stress T1 8 40 14 70 .60).61 .88 37.73 36.00 1. MDD and PTSD for each group and for each phase Positive evolution 18 94.80 1. t test or chi-squared test. 358 V. cut-off point: ICG (25).08) criteria for participation (see Figure 1). Intervention Control Outcome variable M SD M SD df t p Hedges’s g ICG T1 37. T1 ¼ 1st evaluation. 1973) and >35 for the IES-R.99 11. MDD.00 2.84 n.63 .50 Female 17 85 18 90 Male 3 15 2 10 Educational level 3.00 3.91 .51 2. profile of each group. with the highest ES value (g ¼ 3.92 1. 1995a).02 IES R T2 15.s ICG T2 25.75 36.30 1.41 BDI T1 19.0 1. Complicated grief (ICG). 1.01.06 7.3% effect that falls within the confidence interval (95% CI for of the group.06 With traumatic stress T2 0 0 18 90 .80 5. depressive symptoms (BDI). the IG and controls at T1 and T2.05.80 7. .46 39.23.21 23.38 Time since loss (years) 8.63 (Prigerson et al. respectively.44 . MDD n % n % x2(1) and PTSD in groups and their positive evolution In order to calculate the frequencies and prevalence of With complicated grief T1 20 100 20 100 a With complicated grief T2 5 26.50 Perceived difficulty of the situation 9.60 8.53 36.26 5. a decrease for small samples.35 11.05.  p < . had a reduced ICG. at T2. No statistics are computed because complicated grief in T1 is a constant. The controls.59   p < .50 8. BDI (> 12). which allowed us to quantify the number of cases that progressed positively along the longitudinal Note. 2. Of all the variables.25 6.75 41. Frequency and prevalence of CG.00 CG. Intervention Control Comparing the frequency and prevalence of CG.12 Place of death . At T2.00 Serra & Pio Abreu. IES R (>35). and PTSD in evaluation compared to the controls.00 . T2 ¼ 2nd evaluation.7 16 80 .44 . Table 2. Barbosa et al.57 IES R T1 33.50 Expected 8 40 5 25 Unexpected 12 60 15 75 Note. IES R. an ICG cut-off point of 25 was used With depression T1 17 85 18 90 .17 (T1 and T2).25 12. due to the IG demonstrating better results during the second Table 3.45 42. BDI.50 42.99 5. Positive evolution 19 100 8 40 .00 tabs procedure.49 Nursing home status .57–4.62 n. 0. This was one of the initial Pearson chi squared for x2 < .02 .31 34.00 7.98 . all participants had CG.70 10.59).75 0.25 8.58–3.86–2.01.80 Hospital 8 40 9 45 Nursing home 3 15 4 20 Home 9 45 7 35 Downloaded by [University of Liverpool] at 17:16 07 October 2014 Type of death .  T1.. BDI and the IES-R is considerably high (ES values > . Tests of significance according to the variable type.48 analysis of the positive evolution of the IG and controls.00 5.50 Inpatients 13 65 14 70 Outpatients 7 35 6 30 Cause of death .20 1.84 9. the IES-R showed in prevalence of CG in the IG (94. For the Positive evolution 16 84.24 2. Table 1.32 37.  p < . and traumatic symptoms (IES-R): comparison between the IG and controls at T1 and T2.2 15 75 .32 6. as well as >12 for the BDI (Vaz With depression T2 8 42.1 19 95 .98 1.3 19 95 .28 8. Sociodemographic characteristics of IG (n ¼ 20) and controls (n ¼ 20) and significant values of the differences between groups determined using the t test or chi-squared test.

with the IG displaying calculating the value of the Pearson chi square. 2000. the IG showed a positive evolution for 16 cases Discussion (84. At T2. The response options ranged from 0 to 10. had CG. Wittouck et al. indi. the IG contained 8 participants with reducing complicated grief. Therefore. leading to a better and more adaptive life. using the IES-R.79 1. 2003). the controls showed a T2.037 Time IES R Before and after intervention 1 31.69 . 2002a. Neimeyer. depressive and traumatic symp- PTSD. Importance of intervention 19 9..05. Despite these disparate differences along the longitudinal profile. n M SD Table 5 shows that we obtained very satisfactory answers.. 2007. in this case. 2011). Examining Table 4. 2007. Thus. although complicated grief was the main between the two groups. In the first evalua- ness of a four-session cognitive narrative intervention tion. thus.89 . prevalence of CG of (80%) that corresponds to the posi. this randomised controlled trial evaluated the effective- MDD cases in the IG (n ¼ 8. As shown in Table 3. 2002b). Cramer.56 cating that the programme was important for the partici. Help me decide better 19 8. Programme acceptability as judged by the participants.01) for the ICG. there was an between the IG and controls at T1. to deconstruct the metaphors carrying effect (p < . In turn. Neimeyer. We emphasise that the participants see this Additional support 19 9. 1999. 95% of participants still problems..00 Time  groups IES R Before and after intervention 1 44. By the outcome variables (p < . p < . we see that at T2. The results of these sessions are encouraging.1%). The effective- tion for the ICG and IES-R (p < .71 . at T1. afterwards. narrative programme Intervention group participants responded to questions Table 5. but we idea that most people can improve if they discuss their life found significant differences between the groups at T2.67 . Time df F p Time ICG Before and after intervention 1 35.47 Importance of seeking help 19 9. and that it is important to receive such help when solving tive evolution of 16 participants. 2008.001 Time BDI Before and after intervention 1 17. we obtained a value less ment of complicated grief (Boelen et al.00 Time  groups ICG Before and after intervention 1 14.50 with an average variation (approximated) of 8 to 10.01. Multivariate repeated measures (time effect and encouraging patients to face their personal stories and to interception effect) work creatively through their loss is important for the treat- Using Mauchly’s test of sphericity. the BDI and the IES-R com- did not find significant differences between groups in pared to the controls.2%).. Aging & Mental Health 359 Table 4. The IG felt that they received more support . the BDI and the IES-R. narrating the episodes and constructing meaning for their emotions and thoughts (Gonçalves.05.00  p < .48 . To clarify thoughts and emotions 19 7. 1988). we concluded that the allows the patient to reflect on their situation and focus con- intervention programme had a very positive time (T1–T2) cern and. At participants with PTSD. 42.16 .11 1. (p < .. 2000. we lower mean values on the ICG.84 . Greenberg. There is a stay of 19 cases with MDD results of other studies in the area of bereavement.56 pants.96 and emotions. The objective was achieved. In partic- Downloaded by [University of Liverpool] at 17:16 07 October 2014 (95%) in the controls.74 1. while the control group had 14 participants (see toms in bereaved participants and examined differences Table 3). MDD or PTSD. Currier et al.01). Pennebaker et al. while the controls had a positive evolution for This study was part of a wider project that included the 15 cases (75%). we noted the presence of PTSD in there was a large and consistent decrease of symptoms some participants.05) for the BDI and a very positive effect on intercep.01).86 . 1999.82 intervention as an opportunity to clarify their thoughts To live a better life 19 7. 2002b. depression prevalence in both intervention and control participants were similar at T1. regarding the acceptability of the intervention pro- gramme. than . There negative meaning and project alternative and additional was also a positive effect on interception (time  groups) adaptive metaphors onto the future (Gonçalves. and traumatic symptoms (IES R). events. GLM repeated measures for complicated grief (ICG). there were significant differences between groups for positive increase in the evolution of eight cases. The interception is. the expected time effect and a significant interaction (time  IG had a positive development of 100%. rich in meaning for metaphorisation and projecting. CNT is innovative in the sense that the use of meta- GLM do not meet the assumption of sphericity (Bryman & phors. we can be confident that the data from the 2002).00 Time  groups BDI Before and after intervention 1 4. Boelen et al. as clinical focus problem.32 . in contrast with the number of ular. Kato & Intervention group acceptability of the cognitive Mann. as it had no groups). These results reinforce the general frequency and prevalence of CG. additionally. the main effect. depressive symptoms (BDI). ness of this intervention is stronger than previously con- ducted interventions in mourning (Allumbaugh & Hoyt.

157(1–3). Mancini. de Keijser. J.A.. Oeiras: Celta Barlow. Azim. Psychia- contaminated by social desirability. Barbosa et al. of measurement.A. Ehrenreich-May. Maccallum & Bryant. & van den DSM (Gana & K’Delant. 2001). Moreover. 1052–1059. 134(5)... & ensure the well-being of the participants. (2007). V. 57(12). C. as there is growing evidence that the preferred Currier. Castanheira. This study reinforces the We conclude that this investigation. J. Additional research is required to confirm the tion that help is useful. replicate the study in different contexts for generalisation of Bryman. 2007. needing specific intervention Bennett.S.T.. This intervention also had is advisable. June). Opatija. Journal of Abnormal Psychology... increased adherence to intervention programmes (Kato & Downloaded by [University of Liverpool] at 17:16 07 October 2014 Mann. with a reduced importance of promoting brief interventions. & Hoyt.A. complicated grief Cognitive and Behavioral Practice. paves the way smaller number of sessions (Jane-Llopis & Barry. P. sociais: introduç a~o as t ecnicas utilizando o SPSS para Randomised controlled trials should be replicated using windows [Data analysis in the social sciences: introduction larger samples (Bennett. Litz. it is necessary to mental validity. therapist of the intervention programme (Jane-Llopis & 44(5). & Rocha.C. Litz. Wittouck et al. B. J. Second. In the controls. 2007). such as IG. van out intervention proved harmful. in the future. Neimeyer. 2010. form randomisation of the participants in order to consider Frade. Stroebe. and. A. A. is not currently recognised as a diagnostic entity in the Boelen.... an increase in the average total score on the IES-R in T2. Afonso. First. this would result in lowed. 2007). such as cognitive behavioural therapy (CBT) previous losses and emotional clarity on bereavement out- come. This is important to the most effective (Boelen et al. & Rocha. Portuguese validation. & Berman. Boisseau. & Stroebe. (1999). Vieira.A. Another inventario de luto complicado [Validation and adaptation to indication for further research is that although the controls Portuguese inventory of complicated grief]... for instance. 2002. 311–314. J. Journal of Loss and Trauma.. J. Boelen. 1995b. D. D.. then. (2006. 2005. 46(3). C. 718–725. The & Insel. Third.. ‘pathology’ that still is not officially recognised. 2005). depression and posttraumatic stress disorder? A test of incre- tion of the results to men.. as well as to recog. 1999. as well as long-term Editora. Coifman. 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