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Late-life bereavement and complicated grief: A

proposed comprehensive framework
a a
Shruti N. Shah & Suzanne Meeks
a
Department of Psychological and Brain Sciences , University of Louisville , Louisville ,
USA
Published online: 06 Sep 2011.

To cite this article: Shruti N. Shah & Suzanne Meeks (2012) Late-life bereavement and complicated grief: A proposed
comprehensive framework, Aging & Mental Health, 16:1, 39-56, DOI: 10.1080/13607863.2011.605054

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 Aging & Mental Health
Vol. 16, No. 1, January 2012, 39–56

REVIEW ARTICLE
Late-life bereavement and complicated grief: A proposed comprehensive framework
Shruti N. Shah and Suzanne Meeks*
Department of Psychological and Brain Sciences, University of Louisville, Louisville, USA
(Received 30 March 2011; final version received 29 June 2011)

Objectives: The construct of complicated grief (CG) has garnered increased empirical attention since it has been
proposed as a diagnostic category for the upcoming Diagnostic and Statistical Manual of Mental Disorders-V.
The aim of this article is to critically examine construct validity in light of a proposed conceptual framework, with
special emphasis on understanding late-life bereavement.
Method: This is a review article that critically examined current bereavement and grief models. We explored
discriminant and convergent validity between CG and uncomplicated grief (UG) and other psychopathological
constructs in terms of symptom intensity, symptom trajectories, bereavement outcomes, and treatment response.
Results: The findings from this review show mixed support for differentiating CG from other outcomes of
bereavement for the following reasons: (1) a clear boundary between CG and UG has not been adequately
supported, (2) symptoms of CG and bereavement-related depression and anxiety overlap, although there is some
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evidence of incremental validity in that CG symptoms predict global functioning above and beyond symptoms of
depression, and (3) the treatment literature demonstrated that general grief interventions and treatment targeted
for improving depression are ineffective at treating symptoms of CG, whereas interventions specially tailored to
treating CG have been moderately effective. The findings also emphasize the importance of considering
pre-bereavement circumstances, such as preexisting depression, in the conceptualization of broader bereavement
outcome.
Conclusion: There were mixed findings supporting the construct validation of CG. A comprehensive framework
that emphasizes pre-bereavement circumstances was proposed in order to better predict various grief trajectories
and outcomes of late-life loss.
Keywords: pathological grief; grief trajectories; grief frameworks; construct validity; late-life grief

Introduction
Just as the aging process is often associated with the
experience of desirable life events (Norris & Murrell,
1990) such as grandparenthood and retirement, it is
also associated with the experience of less desirable life
events, such as the loss of a loved one (Hansson,
Hayslip, & Stroebe, 2007). Death rate statistics show
that older adults are not only experiencing more
bereavements as compared to their younger counter-
parts, but also have the opportunity to experience the
widest variety of bereavement in terms of type of
relationship to the deceased (US Department of Health
and Human Services, 2010). Bereavement is defined as
the objective condition of having experienced a signif-
icant loss (M.S. Stroebe, Hansson, Schut, &
W. Stroebe, 2008). Late-life bereavements may include
death of a spouse, child, peer, sibling, grandchild, or
even a parent, depending on the breadth of one’s social
and familial network.
The death of a spouse may be one of the most
stressful events a married older adult can endure
(Whitbourne & Meeks, 2010). Prevalence statistics
indicate that in 2007, approximately 29.7% of US
community-dwelling individuals over age 65 were con-
jugally bereaved. The percentage of widowed older
adults also rises with increasing age, and the trend,
according to cohort, is as follows: 17.7% between ages
65 and 75; 37.5% between ages 75 and 84, and 62.1%
over age 85. Additionally, widowhood occurs more
frequently in older women than older men, with
estimates nearing 42.2% for widows and 13.1% for
widowers among US community-dwelling older adults
(Federal Interagency on Age-Related Statistics, 2008).
In addition to being a highly probable event, bereave-
ment in older adulthood may have negative conse-
quences in the areas of emotional, physical, social, and
cognitive functioning (Hansson et al., 2007; Parkes &
Prigerson, 2010; M.S. Stroebe, Schut, & W. Stroebe,
2007). Possible negative consequences associated with
late-life bereavement include exacerbation of preexist-
ing levels of depression (Gilewski, Farberow,
Gallagher, & Thompson, 1991), increased risk for
mortality (Impens, 2005; cf. Stroebe et al., 2007),
impairment in physical functioning (Lee & Carr,
2007), higher levels of financial and global stress
(Norris & Murrell, 1990), emotional and social
loneliness (van Baarsen, van Duijn, Smit, Snijders, &
Knipscheer, 2001–2002), decline in memory functioning
(Aartsen, van Tilburg, Smits, Comijs, & Knipscheer,
2005), increased suicide risk (Erlangsen, Jeune,
Bille-Brahe, & Vaupel, 2004), higher levels of anxiety
if the widowed individual was dependent on the
deceased spouse (Carr et al., 2000), and an overall
risk for developing a mood disorder

*Corresponding author. Email: smeeks@louisville.edu

ISSN 1360–7863 print/ISSN 1364–6915 online

ß 2012 Taylor & Francis
http://dx.doi.org/10.1080/13607863.2011.605054
http://www.tandfonline.com
 40 S.N. Shah and S. Meeks
(Onrust & Cuijpers, 2006). Thus, late-life bereavement,
an unfortunate and inevitable condition, is potentially
also a costly one in terms of both mental and physical
health.
One negative consequence of bereavement that has
garnered increased attention in the past 10–15 years is
grief reactions that demonstrate a more complicated or
atypical course. Grief reactions can be characterized as
greatly heterogeneous and idiosyncratic in terms of
intensity, duration, and adaptation to loss, and refer to
a complex set of emotional responses to loss (Hansson
et al., 2007; Hansson & Stroebe, 2007; van Baarsen
et al., 2001–2002). Prospective and longitudinal studies
of late-life bereavement have demonstrated that the
majority of widowed older adults effectively cope with
bereavement-related stress and eventually adjust to
post-loss functioning, even if they have experienced an
initial peak in depressive symptomatology following
the loss. Such grief reactions can be considered
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common or resilient (Bonanno et al., 2002; Bonanno,
Nesse, & Wortman, 2004; Ott, Lueger, Kelber, &
Prigerson, 2007). Nevertheless, there remains a minor-
ity of older adults who may experience a more difficult
grief course. In a large prospective study including 205
bereaved spouses who were tested prior to the death of
their spouse, then at six- and 18-months post-loss,
Bonanno and his colleagues (2002) demonstrated that
nearly 16% of their sample showed a pattern of
chronic grief characterized by low levels of depression
prior to the loss and elevated levels of depression and
grief at six months post-loss. The chronic grievers also
showed elevated grief symptoms at 18 months post-
loss. A more difficult course of grief was demonstrated
by nearly 8% of their sample, in which these individ-
uals exhibited high levels of depression both pre-and
post-loss (Bonanno et al., 2002). Likewise, Ott and
colleagues (2007) found that 17% of their sample of
older bereaved spouses (N ¼ 141) could be classified as
chronic grievers if scores on grief and depression
measures remained elevated 18-months after the death
of their spouses. These studies suggest either the
exacerbation or development of prolonged depressive
symptoms following the death of one’s spouse signif-
icantly deviated from the trajectories of common or
resilient grief reactions; consequently, such grief reac-
tions are considered to be difficult or complicated in
terms of duration and emotional intensity.
Whereas the aforementioned prospective studies
focused on depressive symptoms following a loss,
current thanatologists recognize that the manifestation
of atypical grief reactions (hereafter referred to as
complicated grief, or CG) can be expressed through
multiple psychological and behavioral pathways. The
phenomenology of CG has been proposed to resemble,
yet manifest distinctly from, diagnostic features of
anxiety, mood disorders, and adjustment disorders,
and has been posited to cause interference in everyday
functioning (Horowitz et al., 1997; Lichtenthal, Cruess,
& Prigerson, 2004; Prigerson et al., 1999) due to the
psychiatric morbidity associated with the loss
(Rozenzweig, Prigerson, Miller, & Reynolds, 1991).
Moreover, because some current thanatologists claim
that existing diagnostic entities in the current edition of
the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR; American Psychiatric
Association (APA), 2000) fail to adequately capture
the supposed psychopathology associated with CG
reactions, several conceptualizations of grief using
diagnostic terminology (cf. Forstmeier & Maerker,
2007; Goodkin et al., 2005–2006; Prigerson et al., 2009)
have been proposed for inclusion in the DSM’s fifth
edition. The recent push to include CG as a DSM
diagnostic entity has resulted in a proliferation of
research examining the nature and phenomenology of
CG compared to typical grief reactions and bereave-
ment-related psychopathology. Most of these studies
explore the construct of CG in terms of convergent and
discriminant validity, and conceptual frameworks that
explain why CG is a valid and distinguishable con-
struct are absent in the literature. Broader models of
bereavement, such as Stroebe and Schut’s (1999) Dual-
Process Model (DPM), mainly focus on the coping
processes associated with a bereavement event.
Predictive models of CG, such as Horowitz,
Bonanno, and Holen’s (1993) Stress Response
Syndrome model of ‘pathological grief’ (Horowitz
et al., 1993, p. 269), are few in number. While these
models attempt to capture the internal experience of
grief, they fail to emphasize contextual factors, such as
social support and culture, which may be important for
predicting bereavement outcomes. An exception is the
recently proposed integrative framework of Hansson
and Stroebe (2007) that attempts to predict short-term
and long-term late-life bereavement outcomes based on
the bereaved individual’s interpersonal factors (e.g.,
lack of social support, culture, religion), intrapersonal
factors (e.g., attachment style, gender), and cognitive
appraisal of the loss. The aim of this article is to
propose a comprehensive framework building on this
study (Figure 1) that overtly considers pre-loss condi-
tions in the prediction of late-life grief outcome. This
article will critically examine how the literature to date
can be interpreted in light of the proposed framework
in an effort to better understand the construct of CG.
A secondary aim is to determine the degree to which
research supports the inclusion of CG as a valid,
standardized diagnostic entity. This article will be
organized in three primary sections: (1) a critical
discussion of bereavement and grief models and the
contributions of our proposed model, (2) an evaluation
of construct validity, particularly with regard to
differentiating CG from uncomplicated grief (UG)
and other psychopathological constructs, and (3) a
synthesis and suggestions for future research.
Current bereavement and grief frameworks
Grief has long been recognized as a universal phe-
nomenon inherent in the life–death cycle of the human
experience (Bonanno, Goorin, & Coifman, 2008;
 Aging & Mental Health 41

(chronic/depressed)
Complicated
Interpersonal factors

Social support

culture, SES, attachment style; mental illness Religious

practices

Finances
history, and symptoms

Cognitive
Pre-loss contextual factors

appraisal

Common
GRIEF coping

Grief outcomes
emotion
regulation
Religious beliefs

Physical health

Functioning

Intrapersonal factors
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Resilient
Figure 1. A proposed framework for bereavement outcomes in late-life.

Breen & O’Connor, 2007; Walter & McCoyd, 2009). Complicated Grief – Revised (ICG-R; Prigerson &
Although grief reactions are recognized as universal Jacobs, 2001) measuring disbelief, yearning, anger, and
phenomena, their manifestations are heterogeneous acceptance, at each six month post-loss interval.
across individuals and groups. Capturing a universal Depression was measured using the single-item
set of symptoms that are necessary to constitute a grief ‘depressed mood’ from the Hamilton Rating Scale
reaction has not been the main focus of extant for Depression (HRSD; Hamilton, 1960). The results
literature; instead, writers have focused on the purpose, supported the assumption that typical grief reactions
coping process, and pathological aspects of grief, progressed in stages, in that the five grief indicators
perhaps beginning with Sigmund Freud’s (1917/1963) reached their respective peaks in the sequence pre-
article Mourning and Melancholia (see a discussion in dicted by Jacob’s stage-theory. However, the time each
Granek, 2010). Freud was one of the first to suggest indicator reached its peak did not match the temporal
that one must endure proper ‘work of mourning’ course posited by stage-theory: the indicators of
(Freud, 1917/1963, p. 166) in order to cope with the yearning, anger, and depression peaked closer together
loss of a loved one. Subsequently, other theorists between months four and seven than was originally
adopted the idea of grief work and task-based models hypothesized. Contrary to the theory, acceptance was
of grief (e.g., Kubler-Ross’ (1969) Five Stages of Grief found to be the most frequently endorsed grief
and Worden’s (2009) Task Model of Mourning) as a indicator, followed by yearning.
method of tracking grief patterns and determining Although Maciejewski et al.’s (2007) study provides
when intervention may be necessary. some support for grief stages, it does not support the
Several reviews have recognized the dearth of assumption that each stage can be defined by a single-
empirical evidence supporting the notion of ‘grief grief indicator. Further, assuming that most bereaved
work’ or stage concepts of grief (Bonanno & Kaltman, people progress through cleanly ordered stages is
1999; Breen & Connor, 2007; Lindstrom, 2002; contrary to the widely accepted recognition that grief
Stroebe, Schut, & Stroebe, 2005; Wortman & Silver, is heterogeneous and idiosyncratic (Hansson et al.,
1989). Maciejewski, Zhang, Block, and Prigerson 2007; Hansson & Stroebe, 2007); use of single items
(2007) empirically examined grief stage-theory based from the ICG-R and HRSD may fail to capture the full
on Jacob’s (1993) hypothesis that a typical response to range of emotional response. Stage-theory also fails to
a natural bereavement occurs through a progression of address how interpersonal and intrapersonal factors
five stages: disbelief, yearning, anger, depression, and contribute to the progression through the various grief
acceptance. The study used prospective data from a stages. Lastly, the stage-theory provides limited infor-
sample of 233 individuals (mean age ¼ 62.9, SD ¼ 13.1 mation regarding grief outcome. For example, can
years; 97.0% European American; 71.2% female stage-theory predict long-term bereavement outcomes
enrolled in the larger longitudinal Yale Bereavement based on whether or how a bereaved individual
Study), who completed items from the Inventory of progresses through the stages? Although stage-theory
 42 S.N. Shah and S. Meeks
provides general information regarding the sequencing
of emotional responding to grief, it is limited in its
utility for predicting who will successfully complete the
process versus who will have CG.
Stroebe and Schut (1999) argued that the grief
work hypothesis (1) is ill defined; (2) does not
effectively address the psychodynamic (e.g., denial,
avoidance, and suppression) and interpersonal (e.g.,
social support) processes inherent in the grieving
process; (3) is overly focused on health outcomes and
neglects the positive outcomes of bereavement; (4)
lacks supporting empirical evidence; and (5) has
questionable generalizability across cultures and
between gender. Their DPM focuses on the adaptive
challenges and array of emotions a bereaved individual
may experience while grieving. The model considers
two types of bereavement-related coping processes:
loss-orientation (LO) and restoration-orientation
(RO). LO processes concern the bereaved person’s
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internal experience of having lost a loved one with a
focus on the attachment to the deceased and emotional
and behavioral responses, such as yearning, rumina-
tion, pleasurable reminiscing, despair, and loneliness.
RO processes involve coping with the challenges
bereaved persons face secondary to the loss, such as
defining new social roles/identities, addressing changes
in living arrangements and finances, and acquiring new
skills to adapt to life without the loved one. Over time,
it is hypothesized that the bereaved individual will
spend less time on LO processes and more time
engaged in RO (Stroebe & Schut, 2010). DPM also
addresses individual differences in bereavement out-
come. Optimal post-loss adjustment is posited to occur
if the bereaved person smoothly oscillates between LO
and RO processes. Difficulties in the grieving process
are posited to arise if the bereaved individual has
trouble oscillating between the two coping processes
(Stroebe & Schut, 1999).
Examination of DPM has shown some limited, yet
promising results. For example, Richardson and
Balaswamy (2001) examined the LO and RO processes
of conjugally bereaved older men (N ¼ 200; mostly
Caucasian) in their second year of bereavement. The
sample was divided into two groups: those who were
bereaved 5500 days (‘Early Bereaved’; n ¼ 100), and
those were bereaved 4500 days (‘Later Bereaved’;
n ¼ 100). The authors found that the Early Bereaved
widowers demonstrated significantly more negative
and less positive affect compared to the Later Bereaved
widows. Linear multiple regression analyses revealed
that (1) certain circumstances, such as losing a wife in a
medical setting, predicted higher levels of negative
affect in the Early Bereaved group, (2) certain resto-
ration variables, such level of involvement with neigh-
bors, predicted less negative affect, and (3) restoration
variables predicted positive affect in the Later
Bereaved group. The findings from Richardson and
Balaswamy (2001) suggest that LO- and RO processes
occur throughout bereavement, and that these pro-
cesses influence the overall psychological well-being.
The results also suggest that LO processes, such as
thinking about the circumstances of the loss, are more
salient in the early part of bereavement, whereas RO
processes became more prevalent over time. Although
the study was cross-sectional and included a racially
homogeneous sample of men only, the findings appear
to lend some support to the DPM.
Another theoretically driven conceptualization of
bereavement outcome derives from Lazarus and
Folkman’s (1984) Cognitive Stress Theory (CST).
CST addresses an individual’s cognitive appraisal and
coping with a stressor. When applied in a bereavement
framework, the loss itself is considered to be the
stressor and the bereaved individual’s cognitive
appraisals (negative and positive) and ability to cope
with the emotional strain and challenges following the
bereavement are posited to influence bereavement
outcome (Stroebe & Schut, 1999, 2010). Together,
DPM and CST have contributed to the development of
the most comprehensive bereavement framework to
date (Hansson & Stroebe, 2007; Stroebe, Folkman,
Hansson, & Schut, 2006). The framework considers the
relationships between the nature of the bereavement, in
terms of LO and RO variables, interpersonal risks
factors (e.g., quality of social support, culture, family
dynamics, etc.), intrapersonal risk factors (e.g., attach-
ment style, intellectual ability, socioeconomic status,
etc.), and appraisal and coping (e.g., positive/negative
cognitive appraisals and emotion regulation), in the
prediction of short-term and long-term bereavement
outcomes (e.g., grief intensity, social reintegration,
psychological well-being, etc.). Unlike past models of
grief that provide limited information about individual
outcome and fail to consider the broader context in
which bereavement occurs, the integrative model
proposed by Stroebe and her colleagues aims to
conceptualize grief outcome in terms of individual
differences in coping with the loss. An area of strength
of this framework is its attempt to integrate the
objective context of the bereavement with the behav-
ioral, affective, and cognitive coping processes inherent
in the grief experience.
An area in need of further empirical examination is
the framework’s emphasis on interpersonal and intra-
personal risk factors as they relate to bereavement
outcome. Thus far, quality or nature of the relation-
ship with the deceased, positive/negative cognitive
processes, and emotion regulation have been shown
to relate to bereavement outcomes, but more work is
needed (cf. Stroebe et al., 2007). Studies examining the
mode of death as a predictor of post-loss adjustment
have had inconsistent results (cf. Stroebe & Schut,
2001). Discrepant and inconclusive associations
between risk factors and bereavement outcome may
be due to the following methodological concerns: (1)
the presence of mediating or moderating variables,
such as age, that help explain the relationship between
presumed risk factors and outcome; (2) the absence of
appropriate control groups (e.g., non-bereaved indi-
viduals) that allow comparison between general risk
 Aging & Mental Health
factors and bereavement-specific risk factors in the
prediction of outcome; (3) the assumption that risk
factors remain static and independent during the
assessment period; and (4) cross-sectional research
designs (Stroebe & Schut, 2001; van der Houwen et al.,
2010). Together, these methodological concerns limit
our understanding of how risk factors contribute to
bereavement outcomes.
van der Houwen et al. (2010) have recently
attempted to address some of the aforementioned
methodological concerns using a longitudinal design,
an extensive pool of risk factors and outcome vari-
ables, and multivariate statistical analyses. Their
sample included 195 bereaved participants who had
lost a first degree relative. The sample was mostly
female (n ¼ 180) and had a mean age of 41.50 years
(SD ¼ 10.96); data were collected via online question-
naires immediately, three months, and six months after
the loss occurred. The results from multilevel modeling
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indicated that certain risk factors differentially pre-
dicted certain outcome measures. For example, unex-
pected death predicted elevated grief and depressive
symptoms, but not emotional loneliness or positive
mood. Financial deterioration following the loss pre-
dicted grief but not depressive symptoms. When
analyzed simultaneously, bereavement-related, intra-
personal, and social/environmental variables
accounted for 24–27% of the variance in the outcome
measures (van der Houwen et al., 2010). These findings
suggest that examining risk factors in isolation may
mask the effects of possible moderating or mediating
variables on various bereavement outcomes, and lend
some support to Stroebe and Schut’s (1999) integrative
bereavement framework. However, in order to identify
who may be most vulnerable to experiencing atypical
post-loss difficulties, consideration of pre-loss condi-
tions such as preexisting psychopathology is also
necessary. The prospective study briefly described in
the introduction of this article by Bonanno and his
colleagues (2002) highlights the importance of consid-
ering pre-loss conditions in the prediction of bereave-
ment outcome. In this study, the authors analyzed data
from 205 older widows and widowers from the
Changing Lives of Older Couples (CLOC) study of
bereavement (as described in Carr, Nesse, & Wortman,
2006). The average age of the sample was 72 years
(SD ¼ 6.5) at baseline; participants were followed at
six- and 18- months post-loss. Preexisting levels of
depression were taken into account in the prediction of
grief course. Grief symptoms were measured using
items derived from three grief measures: the
Bereavement Index (Jacobs et al., 1986), the Present
Feelings about Loss Scale (Singh & Raphael, 1981),
and the Texas Revised Inventory of Grief (TRIG;
Zisook, Devaul, & Click, 1982). Depressive symptoms
were measured using the Center for Epidemiologic
Studies Depression Scale (Radloff, 1977). Five trajec-
tories of grieving were captured: resilient, common,
depressed-improved, chronic depression, and chronic
grief. Although they had similarly negative post-loss
43
trajectories, the chronic depressed group demonstrated
elevated scores of depression prior to the bereavement
event, whereas the chronic grief group did not exhibit
high levels of baseline depression.
The findings from Bonanno et al. (2002) suggest that
consideration of pre-loss depressive symptoms helps
discriminate between two negative bereavement out-
comes: bereavement-related depression (chronic depres-
sion) and CG (chronic grief). Failure to consider
baseline depressive symptoms may result in the assump-
tion that the chronically depressed and chronic grievers
are the same when in fact they may be distinct groups.
Although this comparison does not explain the specific
etiology of CG, other analyses from the same data set
(Bonanno et al., 2002) suggest that both chronic
grievers and chronically depressed individuals showed
higher levels of dependency on the deceased spouse and
general interpersonal dependency. Those who were
chronically depressed perceived themselves as having
poor coping ability, were more neurotic, and exhibited a
negative world view; chronic grievers were more likely
to have had a healthy spouse die, as well as report less
instrumental support compared to other individuals.
To further explore the distinction between the
chronically grieved and chronically depressed,
Bonanno et al. (2004) explored differences in how they
reacted to and processed the loss of a spouse also using a
sample from the CLOC study. They found that chronic
grievers were more likely to search for meaning in their
loss, endorse experiences of yearning and emotional
pangs, and talk and think about the loss six months
post-loss. At 18-months post-loss, chronic grievers
demonstrated a reduction in how often they thought
and discussed their loss, and were more likely to find
meaning in the loss. In contrast, chronically depressed
individuals did not find meaning in their loss, endorsed
experiences of significant yearning and/or emotional
pangs, and were less likely to discuss/think about the
loss at anytime during the assessment intervals.
Whereas prospective studies demonstrate that con-
sideration of several interpersonal and intrapersonal
contextual factors emphasized in Hansson and
Stroebe’s (2007) integrative framework can be impor-
tant in predicting bereavement outcome, explicit con-
sideration of pre-loss depression or other
psychopathology in the broader context of bereave-
ment outcome is not emphasized in this integrative
framework. Our revised framework (Figure 1) explic-
itly considers pre-loss depression, along with other
post-lost risk factors, that will help identify those
vulnerable for negative outcomes prior to the bereave-
ment event. Using such a framework also has clinical
implications, in that it may help identify who may
benefit from preventative or post-loss intervention.
Construct validation of CG: a critical review
The framework illustrated in Figure 1 provides a
starting point for evaluating recent work on the
 44 S.N. Shah and S. Meeks
construct validity (Cronbach & Meehl, 1955) of CG as
a potential diagnostic entity distinct from depression or
other pathological constructs. The next portion of this
article will critically examine studies attempting to
differentiate CG reactions from UG reactions and
existing psychopathological constructs. Demonstration
of discriminant validity, or the degree of dissimilarity
between two constructs (Campbell & Fiske, 1959), will
be the focus of the review. Studies examining differ-
ential treatment response between those who are
considered have CG versus typical grief will also be
explored, with the assumption that the construct of
interest should respond to treatment differently com-
pared to other constructs (Chambless & Hollon, 1998).
In evaluating the extant literature, it is important to
note that there are no universal criteria that define
‘normal’ grief; the conceptualization of grief may differ
among persons, and cultures, and be defined differ-
ently across researcher groups. Empirical examination
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of the similarities and differences among ‘normal’ grief,
‘complicated’ grief, and existing psychopathologies
may be biased in terms of measurement, sample
selection, interpretation of results, and the culture in
which the research was conducted. The tension
between cross-cultural heterogeneity and the Western
medicalization of psychological constructs is a funda-
mental critique of all psychological disorders included
in the DSM (Beutler & Malik, 2002); this tension is
especially pertinent for grief and deserves special
consideration when attempting to conceptualize a
phenomenon that is both innate and culturally
shaped in a medicalized manner (as discussed in
Hogan, Worden, & Schmidt, 2003–2004). The impli-
cations for considering culture in conceptualizations of
grief will be provided in the closing section of this
article.
Uncomplicated vs. CG
An UG course has been conceptualized as the eventual
recovery from a significant loss, given the typical stress
that often accompanies bereavement (Zhang,
El-Jawahri, & Prigerson, 2006). The point at which a
normal response to loss becomes complicated/patho-
logical has proven to be difficult to pinpoint in terms of
duration and severity of grief symptoms (Holland,
Neimeyer, Boelen, & Prigerson, 2009), or level of
functional impairment associated with the bereavement
event (Prigerson & Maciejewski, 2005–2006).
Research attempting to validate instruments speci-
fically measuring CG, such as the ICG (Prigerson
et al., 1995a) and the Inventory of Traumatic Grief-
revised, Dutch Version (ITG-r; Boelen, van den Bout,
Keijser, & Hoijtink, 2003) against measures of general
grief, such as the TRIG, Grief Measurement Scale
(GMS; Jacobs et al., 1986) and the Hogan Grief
Reaction Checklist (HGRC; Hogan, Greenfield, &
Schmidt, 2001) have provided mixed results regarding
discriminant validity. Because general grief and CG
measures are all assessing grief in some fashion, they
would be expected to correlate highly, but not so
highly as to conclude they are measuring the same
construct. In a validation study of the ICG, Prigerson
et al. (1995a) administered the ICG, GMS, and TRIG,
along with the Beck Depression Inventory (BDI; Beck,
1967) and questions pertaining to demographics and
quality of life, to a sample of 97 conjugally bereaved
older adults. Significant correlations between the ICG
and TRIG (r ¼ 0.87, p50.001) and GMS (r ¼ 0.70,
p50.001) were found. Despite these relatively high
correlations with measures of general grief, the authors
compared outcomes between those who scored 425
(top 20%; ‘complicated grievers’) and 525 (‘uncompli-
cated grievers’) on the ICG. Higher scores on the ICG
indicate more frequent CG symptom endorsement.
The complicated grievers demonstrated worse quality
of life scores, in terms of general, social, physical, and
pain indicators, compared to uncomplicated grievers.
When similar comparisons were conducted for the
20% who scored highest on the TRIG, significant
relationships between lower quality of life were found
in terms of general, physical, and social functioning.
Similarly, Boelen, van den Bout, de Keijser, et al.
(2003) found a significant correlation of 0.70 (p50.05)
between scores on the ICG-r and TRIG. Together,
these findings provide stronger evidence for conver-
gent, rather than discriminant validity between CG
and UC. In other words, the studies demonstrate that
CG may slightly differ from UC in terms of severity,
but not necessarily quality.
Confirmatory factor analytic (CFA) techniques
have been employed to further explore the boundary
between CG and UG and thus far, the findings have
been limited and mixed. Hogan et al. (2003–2004)
failed to demonstrate a distinction between typical
grief and CG measured by using the CG Criteria
(CGC) proposed by Prigerson and Jacobs (2001). Their
sample of 166 participants included predominantly
middle-aged, married females, most of whom were
grieving the loss of a child with a mean time since death
of 4.18 years (SD ¼ 3.50 years). The sample was
recruited from an organ donor foundation. Using a
correlational matrix to analyze the relationships
between the dimensions of traumatic distress and
separation distress within the CGC and six factors
(despair, panic behavior, blame/anger, detachment,
disorganization, and personal Growth) of the HGRC,
Hogan et al. (2003–2004) found that the factors from
the two measures demonstrated stronger evidence for
convergent, rather than discriminant validity.
Furthermore, using a varimax rotation for a forced
principal components analysis on two factors, the
authors found that the two CG categories clustered
closely with two factors of HCRC, despair and blame.
Together, the results from this study failed to demon-
strate that complicated and UG are conceptually
distinct constructs.
Using CFA techniques across three samples
(N ¼ 130, N ¼ 48, and N ¼ 64), Boelen and van den
 Aging & Mental Health
Bout (2008) demonstrated that UG, as measured by
the TRIG, was distinct, but related to CG, as measured
by the ICG-r. The sample (N ¼ 242) consisted of
mostly middle-aged women (79.3%) who had lost their
partners (47.1%) average of 52.5 (SD ¼ 69.9) months
prior to measurement. Most of the deaths were due to
illness (50.4%), and all the participants sought help
post-loss. Using regression analyses, the authors found
that CG factors accounted for a unique portion of the
variance in mental health and quality of life outcomes.
In an attempt to replicate the Boelen and van den Bout
(2008) findings Dillen, Fontaine, and Verhofstadt-
Deneve (2008) conducted similar analyses on a sample
of Dutch college students. Approximately, half the
sample lost a grandparent, and the average time since
loss was 4.24 years (SD ¼ 3.99). Over half the deaths
were caused by illness. Similar to Boelen and van den
Bout (2008), Dillen et al. (2008) demonstrated that
factors of CG and ‘normal grief’ were distinct but
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related based on findings using factor analytic tech-
niques comparing items on the ICG-r, TRIG,
and CGC.
In sum, these studies attempting to differentiate
CG from UC have raised doubt about the claim
that CG is distinguishable in terms of factor structure,
but CG may have some discriminant validity when
used to predict other outcomes, such as quality of life
or mental health. These findings suggest that addi-
tional information, such as level of depression or
quality of life, is needed to demonstrate a more discrete
boundary between normal and pathological grieving.
Current thanatologists recognize that research to date
has inadequately addressed the boundary, and that the
differentiations made have been largely acontextual
(Breen & Conner, 2007; Lichtenthal et al., 2004;
Stroebe et al., 2000). The findings appear to lend
support for using a comprehensive assessment of
multiple factors in the prediction of bereavement
outcome. The issue of sample selection is also an
area of concern when attempting to apply the findings
to a more diverse population. The implications of
limited generalizability, an issue prevalent across much
of the thanatological literature, will be discussed
further in the concluding sections.
CG reactions vs. other psychopathology
Many symptoms of CG overlap or closely resemble
symptoms of depression and anxiety (Boelen, van den
Bout, & de Keijser, 2003; Bonanno, 2006; Horowitz
et al., 1993; Prigerson et al., 1995b, 1996; Prigerson &
Maciejewski, 2005–2006, Stroebe et al., 2008;
Thompson et al., 2007). Lichtenthal et al. (2004) and
Gray, Prigerson, and Litz (2004) provide comprehen-
sive reviews of the CG literature in terms of how CG
has been shown have distinct phenomenology, unique
risk factors and outcomes, and differential diagnostic
discrimination and treatment responses, compared to
Major Depressive Disorder (MDD), Post-Traumatic
45
Stress Disorder (PTSD), and Adjustment Disorder as
outlined by the DSM-IV-TR (APA, 2000). Based on
the studies reviewed, the authors make the case that the
research has adequately demonstrated CG to be a
unique and distinguishable construct worthy of its own
standardized diagnostic criteria. However, the authors
minimally address a common limitation found in
current grief-related research: limits to generalizability
due to issues related to sample selection. Several
studies examining the uniqueness of CG have been
conducted since Gray et al. (2004) and Lichtenthal
et al. (2004); in our review of these studies, we give
special attention to how sample selection issues influ-
ence the interpretation of the results and to how the
findings contribute to our proposed framework.
Table 1 lists seven recent studies that explored the
uniqueness of CG compared to symptoms of anxiety
and depression. Six out of the seven studies concluded
that symptoms of CG were related to, but distinct
from, symptoms of anxiety and depression using a
variety research designs and statistical analyses. For
example, Boelen and van den Bout (2005) administered
the Dutch version of the ITG and the depression and
anxiety subscales of the Dutch Symptom Checklist-90
(SCL-90; Arrindell & Etterma, 2003 as cited in Boelen
& van den Bout, 2005) to a sample of 1321 self-selected
Dutch mourners (mean age ¼ 43 years; 82% female).
Using CFA, the authors found three distinct clusters of
CG, bereavement-related depression, and anxiety in
their model. Moderate correlations were found
between factors of CG and depression (r ¼ 0.78) and
anxiety (r ¼ 0.58), providing evidence that the symp-
tom clusters represented distinct, but related con-
structs. These correlations were similar to those found
in Boelen and Prigerson (2007), Bonanno et al. (2007),
Langner and Maercker (2005), and Prigerson et al.
(2009). The correlations found by Boelen and col-
leagues (2010) between CG and depression and PTSD
were slightly higher (r ¼ 0.75–0.78 and 0.85–0.87,
respectively). Despite stronger evidence for convergent
validity, the authors concluded that symptoms of CG
are distinguishable from symptoms of depression and
PTSD. Hogan et al. (2003–2004) were the only authors
to conclude their findings failed to adequately demon-
strate discriminant validity between depression, as
measured by the Beck Depression Inventory-II (BDI-
II; Beck, Steer, & Brown, 1996), and the symptoms
related to CG as defined by Prigerson and colleagues
(1999), despite the fact that their correlations were
similar to those in the other studies cited. Using
principle components analysis with varimax rotation,
Hogan and colleagues (2003–2004) also found a high
degree of shared variance between depression and
separation distress (46.5%) and depression and trau-
matic distress (53.1%). As a whole, the studies listed in
Table 1 lend additional support to the general conclu-
sions drawn from the reviews by Lichtenthal et al.
(2004) and Gray et al. (2004), in favor of discriminant
validity of CG. One study (Bonanno et al., 2007)
demonstrated incremental validity using hierarchical

Table 1. Studies examining the uniqueness of CG.
Study
Hogan et al. (2003–2004)
Langner and Maercker (2005)
Boelen and van den Bout (2005)
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46
Design/Method/
Sample Analyses Definition of CG Variables/Measures Major findings
N ¼ 166, member of an Retrospective Feelings of separation –CG disorder criteria –Significant relationship
organ donor founda- –CFA distress (longing, –Normal grief: HGRC between depression
tion –Principal components yearning, and loneli- –Depression: BDI-II and separation dis-
–77.1% female analysis with varimax ness) and traumatic tress (r ¼ 0.68,
–78.4% married rotation distress (stunned, r 5 0.001) and trau-
–Mean age: 49.17 dazed, empty, in matic distress
–74.7% lost a son shock) lasting at least (r ¼ 0.73, p 5 0.001)
–Mean time since death: 2 months after the loss 46.5% shared variance
4.18 years (SD ¼ 3.50) and causes functional between depression
–65.4% died in accident impairment and separation dis-
tress and 53.1%
between depression
and traumatic distress
No evidence of divergent
validity between CG
and depression
N ¼ 75, recruited via Retrospective –Based on stress- Complicate grief module –Correlations between
advertisements, self- –Spearman correlations response theory : CG (CGM), German ver- the three CGM cate-
help groups, and peers –Regression analyses is a combination of sion – interview based gories and all other
–Ethnicity: German avoidance, intrusions, CG measure psychopathologic
–Mean time since loss: and failure to adapt to –Three categories: measures 0.39–0.75,
5.4 years (SD ¼ 3.5) a loss after a bereave- avoidance, intrusion, p 5 0.1
–85.1% female ment event and failure to adapt –32.8–54.0% of the var-
Mean age: 44.2 years Depression: BDI, iance between BDI
–10% widowed German version and respective IES-R
S.N. Shah and S. Meeks
–Majority highly edu- Anxiety: BAI, German subscales was
cated version explained by relative
–Religion: 41.7% unde- PTSD: impact of event CGM subscales
nominational scaled-revision, –Shared variance sug-
–60% lost a sibling German version gests that construct of
–75.4% lost someone (intrusion, avoidance, CG shares PTSD
due to unforeseeable and hyper arousal symptomatology, but
circumstances subscales) can also be considered
to be a distinct
phenomenon.
N ¼ 1321, self-selected Retrospective Not explicitly given, but Distress: SCL-90-revi- CFA: 3 distinct clusters
mourners CFA used separation dis- sied, German version of CG, bereavement-
–Ethnicity: Dutch tress and traumatic General grief: TRIG, related depression and
–Age: 43 distress criteria of German version (un- anxiety
–Gender: 82.1% female traumatic grief validated) –Moderate correlations
–81.4% died via nonvio- ICG, Dutch version between symptom of
lent ways Depression and anxiety: CG and depression
SCL-90 subscale and (r ¼ 0.78), and anxiety
various DSM criteria (r ¼ 0.58)

Boelen and Prigerson (2007)
Bonanno et al. (2007)
(study 1)
Bonanno et al. (2007)
(study 2)
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N ¼ 346 Prospective longitudinal Based on criteria for ICG-R –Symptom clusters
–Ethnicity: Dutch? (n ¼ 96) PGD (Prigerson et al., Depression and anxiety: represent distinct, but
–Bereaved between 6 –CFA 1999) subscales of the SCL related constructs
and 24 months –Regression analyses, –Separation distress Quality of life: Rand CFA: depression,
–276 women –Baseline, 6-months and –Cognitive, emotional, Health Survey anxiety, and PGD
–Age: 48 15 months behavioral symptoms –Questions of suicide were distinct, but cor-
–211 lost a partner –Functional impairment ideation, sleep related
–157 lost someone due to for 6 months –PGD and depression:
illness r ¼ 0.75
Mean time since loss: –PGD and anxiety:
14.46 months r ¼ 0.56
N ¼ 73 Longitudinal CG should predict psy- Structured clinical inter- Regression: PGD pre-
–Recruited from –4 (Wave 1) and 18 chological functioning views of CG, MDD dicted unique mental
Washington, DC area months (Wave 2) above and beyond and PTSD, GAF health and reduced
–Age: 51.7 years post-loss that of depression and –Autonomic responsiv- quality of life out-
–Gender: 65% female –Hierarchical regression PTSD ity (at 4 months post comes at 6 months
Race: 89% Caucasian analyses (CG should demonstrate loss) was recorded, and 15 month post-
–53 conjugally bereaved incremental validity) while the patient was loss
–20 parentally bereaved CG was defined as told to describe the (demonstration of incre-
meeting five or more relationship with the mental validity of
CG symptoms deceased, their current PGD)
life, and a recent –39% of participants
negative event. who met criteria for
–Informant rating of the CG (n ¼ 13) did not
participant’s meet criteria for
functioning MDD or PTSD at 4
months
57% of those who met
criteria for CG (n ¼ 7)
at 18 months did not
meet criteria for
Aging & Mental Health
MDD or PTSD
N ¼ 447, bereaved from Cross-sectional See above –Depression: Major –High intercorrelations
11 September 2001 –2.5–3.5 post-loss –Based on the criteria of Health Questionnaire between symptoms of
terrorist attacks, –Hierarchical regression PGD –PTSD: PTSD CG, PTSD, and
recruited from 9/11 model –Yearning, and at least Checklist-Civilian MDD were found
websites five of the following Version –MDD and CG: (at W1,
–77.4% female symptoms: numbness, –CG reactions: 9-item r ¼ 0.63, at W2,
–Age: 45 stunned, mistrust, bit- screening measure r ¼ 0.59)
–Income: 83% terness, difficulty developed by –PTDS and CG: (at W1,
earned $40,000 accepting the loss, Prigerson Diagnosed r ¼ 0.68, at W2,
–Race: 94% identity confusion, if answered often or r ¼ 0.49)
Caucasian avoidance, difficulty always on at least –CG symptoms uniquely
–Completed 4 years of moving on with life 5 items explained (5%) of
college: 68% –Symptoms must be Global Functioning: GAF variance, 2%
–From the Yale experience highly at Medical Outcome for PTSD and 3% for
Bereavement Study of least 6 months from Study Short Form depression
community-dwelling the death and cause Health Survey –Similar pattern of
bereaved individuals functional impairment Prolonged grief: ICG-R results when GAF
–N ¼ 317 Psychiatric disorders: based on informant
47
(continued )
 Downloaded by [Selcuk Universitesi] at 05:51 23 January 2015

48
Table 1. Continued.

Design/Method/
Study Sample Analyses Definition of CG Variables/Measures Major findings

–Mean age: 61.8 SCID (anxiety and ratings

–73.7% female mood disorders) –CG had opposite effect
–95.3% white –Suicide ideation: Yale predicting heart rate
–83.9% conjugally Evaluation of response versus PTSD
bereaved Suicidality –39.8% met criteria for
–60.4% 12þ years edu- –ADLs and physical CG, 55% of these did
cation functioning: not meet criteria for
Of this, 291 individuals Established population MDD or PTSD
were included in the for epidemiological –High intercorrelations:
study studies of the elderly CG and Depression:
–Quality of life: medical r ¼ 0.49
outcomes CG and PTSD: r ¼ 0.66
Short form –Depression and CG
predicted reduced
functioning, but
depression uniquely
accounted for more
variance in function-
ing (5%) than did CG
(2%)
–Established consensus
criteria for PGD,
based on Horowitz’s
algorithm (convergent
S.N. Shah and S. Meeks

validity with a pre-

viously proposed
diagnostic algorithm,
 ¼ 0.68), and discri-
minant validity: T
with MDD ¼ 0.36;
PTSD ¼ 0.31;
GAD ¼ 0.17
Prigerson et al. (2009) N ¼ 572, recruited via Longitudinal –Based on criteria of PGD: 9 items from the –Showed that diagnos-
internet ads –Baseline (6.3 months PGD, as measured by ICG-r, Dutch version ing PGD 0–6 months
–Mean age: 43. 2 post-loss) and two the ICG-r Depression: depression post-loss does not
–90.2% female follow-up visits subscale from Dutch predict functioning at
–Majority lost either a (10.9 and 19.7 SCL 12–24 months post
spouse or parent months post-loss) PTSD: PTSD symptom lost
–Mean time since loss: scale self-report –Demonstrated three
44.7 months (SD ¼ 80) version temporal subtypes
–60.1% experienced a (acute, delayed and
non-sudden loss persistent)
–Demonstrated the
 Downloaded by [Selcuk Universitesi] at 05:51 23 January 2015

sensitivity (1.00), spe-

cificity (0.99), positive
predictive value
(0.94), negative pre-
dictive value (1.00) for
the PGD criteria after
6 months post-loss
–Symptoms of PGD
were distinguishable
from depression and
PTSD
Boelen et al. (2010) N ¼ 408, recruited from CFA, item information See above PGD: 9 items from the –Correlations:
(sample 1) a larger study via function analysis, dif- ICG-r, Dutch version Sample 1:
(sample 2) mental health workers ferential item func- Depression: BDI –PGD and depression:
–Mean age: 53.7 tioning analysis PTSD: PTSD symptom 0.78
–77.7% female Retrospective scale self-report –PGG and PTSD: 0.87
–57.6% lost a spouse CFA version Sample 2:
–Mean time since loss: Cross-validation sample –PGD and depression:
5.1. months 0.75
–62% experience a non- –PGD and PTSD: 0.85
sudden loss –Provides evidence that
PGD symptoms are
distinct from, but
related to symptoms
of depression and
PTSD
–Using the cross-valida-
tion sample, the
authors were able to
Aging & Mental Health

demonstrate general-
izability of the
findings
49
 50 S.N. Shah and S. Meeks
regression analyses, in that the prediction of global
functioning, CG symptoms uniquely explained the 5%
of the variance in global functioning, more than the
variance accounted for by depression and PTSD
symptoms.
A closer examination of these studies reveals
sample-selection and methodological concerns that
warrant caution when interpreting the findings. First,
much of bereavement research under-represents men
(Breen & Conner, 2007; M.S. Stroebe, W. Stroebe, &
Schut, 2003). The samples are also predominantly
European (Dutch or German) or European American,
limiting the degree to which the findings can be
generalized across more diverse populations. Issues
with sample demographics are more than likely due to
recruitment methods, as the participants are often self-
selected via the internet, personal referrals from
religious affiliations, self-help groups, organ donor
foundations, and medical or mental health profes-
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sionals (Bonanno & Katlman, 1999); bereaved women
are more likely than bereaved men to seek help from
external supports, respond to recruitment advertise-
ments, and openly discuss their grief reactions.
Previous research has suggested that the sex difference
in bereavement research participation may be due to
differential coping styles and affective response to loss
between the sexes (M.S. Stroebe & W. Stroebe, 1989–
1990; Stroebe et al., 2003). However, gender differences
in how men and women respond on CG measures, in
terms of severity, have not been found (Boelen & van
den Bout, 2003). Only one study listed in Table 1
explicitly attempted to control sample selection bias.
Langner and Maercker (2005) recruited bereaved
participants who were less prone to engage in help-
seeking behaviors within one year post-loss. With one
exception (Prigerson et al., 1999), the other studies
included in Table 1 fail to mention specific population
in which their findings may be most interpretable
despite commenting on the limits of generalizability of
their findings.
Four of the seven studies included in Table 1 are
retrospective. Although such designs are convenient to
both researchers and participants, the accuracy of
self-reported information may be questionable, as the
individual may be influenced by the stress of the
bereavement event and/or respond in a biased fashion
(Stroebe et al., 2003). In studying the retrospective
reappraisals of bereaved spouses, Safer, Bonanno, and
Field (2001) demonstrated that accuracy of a retro-
spective account of the intensity of grief is influenced
by the degree of coping with the loss. Overestimations
of prior grief reactions were more present in spouses
whose grief reactions did not show improvement over
time. Consequently, in regard to the retrospective
studies included in Table 1, bereaved individuals who
were scoring highly on CG or general grief measures
may have been biased in their response style (e.g.,
overestimating their past grief reactions), therefore
possibly influencing the accuracy of their reporting of
grief reaction since the time of loss. Explicit
comparisons between recently bereaved participants
(51 year) and those who have been bereaved for a
longer time (e.g., four years) could help control for
possible memory bias in retrospective designs.
Three studies in Table 1 employed longitudinal
designs. While demonstrating the uniqueness of CG
reactions as compared to anxiety and depression, the
longitudinal designs revealed that the presence of
heightened grief symptoms was predictive of mental
health problems and reduced quality of life (Boelen &
Prigerson, 2007). Bonanno et al. (2007) demonstrated
that CG symptoms predicted global functioning when
depression and PTSD symptoms were controlled. The
authors also demonstrated that PTSD and CG symp-
toms differentially predicted autonomic responsivity,
in that PTSD symptoms were a stronger predictor of
heart rate change than CG symptoms. Prigerson and
colleagues (2009) established, in addition to diagnostic
discriminant validity, the six month temporal criteria
for Prolonged Grief Disorder (PGD), as grief symp-
toms present six months post-loss were more predictive
of functioning 12–24 months post-loss than symptoms
assessed prior to six months from the time of the
bereavement event.
While consistently demonstrating a degree of sepa-
ration from other pathology, CG alone does not appear
to be a powerful predictor of functional outcomes. As
emphasized earlier, consideration of pre-loss risk fac-
tors, such as preexisting depression, may be especially
helpful in predicting grief and depression trajectories
following a loss (Bonanno et al., 2002). The studies in
Table 1 remain largely acontextual. Our proposed
framework incorporates not only the post-loss pro-
cesses and resources that have been show to predict or
differentiate bereavement outcomes, but also contex-
tual factors that existed prior to the loss.
Treatment response and outcome
A final consideration in examining the construct
validity of CG is whether it responds uniquely to
treatment. A major argument for validating CG and
for its inclusion as a diagnostic entity is the need for
proper detection, prevention, and treatment for those
who may evidence significant and impairing post-loss
difficulties (Boelen, van den Schoot, van den Hout, de
Keijser, & van den Bout, 2010; Jacobs, Mazure, &
Prigerson, 2000; Prigerson et al., 2009; Zhang et al.,
2006). That is, should CG symptoms be treated
differently than the anxious or depressive symptoms
that they resemble? Recently, the theoretical basis,
utility, efficacy, and effectiveness of grief counseling
have been called into question by several leading
bereavement and/or psychological intervention
researchers (e.g., Bonanno & Lilienfeld, 2008; Breen
& O’Conner, 2007; Currier, Neimeyer, & Berman,
2008; Jordan & Neimeyer, 2003; Lilienfeld, 2007;
Lindstrom, 2002; Stroebe et al., 2005). Meta-analyses
and comprehensive reviews examining the effectiveness
 Aging & Mental Health
of general bereavement interventions have demon-
strated unimpressive effect sizes, thus challenging the
dominant discourse of the helpful nature of grief
counseling (e.g., Allumbaugh & Hoyt, 1999; Currier
et al., 2008; Kato & Mann, 1999). However, current
researchers have argued that sweeping statements
announcing the ineffectiveness of grief interventions
lose sight of the findings of relative improvement in
individuals considered to be at heightened vulnerability
for experiencing CG. For example, although Currier
and colleagues (2008) found an overall moderate effect
size for bereavement intervention, studies (n ¼ 5) that
only included participants with bereavement-related
difficulties showed greater post-treatment benefits
(mean effect size ¼ 0.53, p40.05). In studies that
have compared treatment responses between partici-
pants with CG versus depression, when the treatments
were either psychological or pharmacological interven-
tions for depression, grief symptoms remained elevated
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and stable for those with CG, while depressive symp-
toms diminished for both CG and depressed patients
(see reviews by Auster, Moutier, Lanouette, & Zisook,
2008; Hensley, 2006; Lichtenthal et al., 2004). Three
studies reviewed (Auster et al., 2008; Hensley, 2006)
failed to demonstrate differential treatment responses
from antidepressant medication: both depression and
grief symptomatology improved. Whereas the studies
covered in these reviews show some support for
differentiating CG and depression, typically small
sample sizes and sample homogeneity limit the gener-
alizability of the findings to more diverse bereaved
populations (Lichtenthal et al., 2004).
More recently, attention has been turned to the
development of theoretically derived treatments spe-
cific to CG reactions, as compared to grief interven-
tions that are more universal and nonspecific (Smith,
Kalus, Russell, & Skinner, 2009). These interventions
include cognitive behavioral grief therapy (Boelen,
2006; Matthews & Marwit, 2004), CG Treatment
(Shear & Frank, 2006), Traumatic Grief Treatment
(Shear et al., 2001) meaning-making and narrative
techniques (Neimeyer, 2006), internet-based emotive
therapy (Botella et al., 2008), short-term group therapy
(Piper, 2006), exposure techniques (Horowitz et al.,
1997), and techniques commonly used in treatment of
PTSD, such as stimulus discrimination, memory
updating, and reclaiming one’s life (Ehlers, 2006). To
date, five studies have examined the efficacy of
interventions specially tailored to treat CG reactions
(Boelen, de Keijser, van den Hout, & van den Bout,
2007; Shear et al., 2001; Shear, Frank, Houck, &
Reynolds, 2005; Wagner, Knavelsrud, & Maercker,
2006; Wagner & Maercker, 2007). Overall, these
studies have demonstrated moderate-to-large effect
sizes. CG symptoms demonstrated clinically significant
reductions over the course of treatment at a faster
response rate than traditional interpersonal or sup-
portive counseling interventions (Shear et al., 2005).
Boelen and colleagues (2007) and Wagner and
Maercker (2007) demonstrated that therapeutic gains
51
were maintained over a course of six months and
1.5-years, respectively, after post-treatment.
Exclusionary criteria, reasons for attrition, treatment
adherence, and intent-to-treat analyses were suffi-
ciently addressed for most studies. The treatment
rationales were theoretically grounded in either
stress-response theory (Horowitz et al., 1993) or dual-
process theory (Stroebe & Schut, 1999). As a whole,
the results from these intervention studies have proven
to be much more promising than past general grief
intervention studies and are worthy of further empir-
ical study. However, the studies inadequately
addressed and controlled for the prevalence of
co-morbid Axis I diagnoses in their samples, particu-
larly MDD and/or PTSD. Reductions in depression
and anxiety scores were, for the most part, associated
with reduction in CG symptomatology. Individuals
with comorbid Axis I disorders have shown to endorse
CG symptomatology at higher levels than those
without such diagnoses (Melham et al., 2001).
Because of the CG interventions employed in the
experimental condition closely resemble empirically
supported treatments of PTSD and depression (e.g.,
cognitive-behavioral therapy), it is hard to determine
the mechanisms by which therapy specifically reduced
symptoms of CG. Thus, the degree to which the
treatment studies demonstrate divergent validity, in
terms of unique treatment response, cannot be clearly
determined at this time.
Summary and future directions
The primary aim of this article was to explore the
construct validity of CG and to propose a bereavement
outcome framework to guide future research that
might be especially relevant to older adults. The
findings from this review show mixed support for
differentiating CG from other outcomes of bereave-
ment for the following reasons: (1) a clear boundary
between CG and UG has not been adequately
evidenced, (2) symptoms of CG, and bereavement-
related depression and anxiety overlap, although there
is some evidence of incremental validity in that CG
symptoms predict global functioning above and
beyond symptoms of depression, and (3) the treatment
literature has demonstrated that general grief inter-
ventions and treatment targeted for improving depres-
sion are ineffective at treating symptoms of CG,
whereas interventions specially tailored to treating
CG have been moderately effective although the
therapeutic mechanisms by which these treatments
operate are unclear. A conceptual framework from
which clinicians and researchers could interpret these
findings may serve as a useful tool in understanding the
construct underlying CG (Hansson & Stroebe, 2007;
Stroebe et al., 2006). The integrative framework
proposed Stroebe et al. (2006) illustrates the multi-
dimensional relationship among the nature of the
bereavement, post-loss inter- and intrapersonal factors,
 52 S.N. Shah and S. Meeks
and the bereaved person’s cognitive appraisal as
predictors of bereavement outcome. However, consid-
eration of pre-loss circumstances, such as preexisting
depression, appears to be critical in separating CG and
bereavement-related depression, and may be important
for differentiating other bereavement outcomes as well.
Our proposed framework incorporates pre-loss cir-
cumstances in the prediction of bereavement outcomes.
As we have repeatedly pointed out, sample homo-
geneity is a common problem in the grief literature.
The majority of samples are comprised of middle-aged,
Caucasian women. Sampling homogeneity may be the
result of recruitment methodology, as women may be
more likely to respond to recruitment advertisements
and seek external help from support groups or profes-
sionals which operate as a referral source for research,
and ultimately participate in bereavement-related
research (Bonanno & Kaltman, 1999; Stroebe et al.,
2003). The degree to which research findings based on
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homogeneous group of individuals translate to more
diverse populations has yet to be adequately addressed.
Grief-related rituals, mourning practices, and views of
death and dying vary across cultures, and these
culturally sensitive aspects of a bereavement event
may influence the internal experience of grief
(Rosenblatt, 2008). Although it has been argued that
culture plays a larger role in the behavioral expression
than the intrapersonal experience of grief (Cowells,
1996), culture cannot be ignored when aspects of grief
may be deemed pathological (Beutler & Malik, 2002).
Relatively few studies have empirically examined
differences in the experience of grief, let alone CG,
across cultures (e.g., Catlin, 1993; Lalande & Bonanno,
2006). For example, Lalande and Bonanno (2006)
examined differences in how participants in China
(n ¼ 58) versus the United States (n ¼ 61) adapted to
loss across four and 18-month assessment intervals.
The authors found that the Chinese participants who
exhibited high levels of continuing bonds at 4-months
demonstrated better adjustment to the loss at 18-
months. American participants who demonstrated
higher levels of continuing bonds were shown to be
less adjusted at 18-months post-loss. Until more
culturally heterogeneous samples have been explored,
it may be safest to conceptualize CG as being a
culturally bound syndrome.
Because older adults are the most frequently
bereaved population group under normal circum-
stances, examining the nature of late-life grief, and its
possible complications, is clearly in need of further
exploration. Only a handful of articles discussed in this
article have based their findings on data collected from
older adults (Bonanno et al., 2002, 2004; Prigerson
et al., 1995b; Ott et al., 2007). None of the CG
intervention studies mentioned above based their
findings on an older adult population, which is a
limitation in both the bereavement and psychotherapy
literatures. Research has shown that younger adults
suffer more intense grief reactions than older adults,
and this could be due the fact that death at a younger
age is untimely and often unpredictable (Hansson &
Stroebe, 2007). This differential finding may also be
due to age-related changes in emotional functioning.
For example, Socioemotional Selective Theory (SEST;
Carstensen, 1995) posits that older adults tend to
experience more positive emotions as they age, despite
the frequency and breadth of loss they may experience.
The theory takes into consideration the motivational
consequences of perceived time left to live. From this
theory, it can be hypothesized that when death seems
near, older adults tend to pursue emotional satisfaction
despite how much loss they have endured. Studies,
such as Bonanno et al. (2002) and Ott et al. (2007) have
shown that the majority of older adults endure grief
without emotional or psychological complications, and
this appears to be consistent with the assumptions of
SEST. However, these studies also demonstrated that
there is a group of older adults who experience more
CG courses, and further theoretical exploration is
required to understand why this is so, but we would
expect failure of expected grief recovery could result
from pre-loss risk factors as well as from post-loss
support and processes for coping. Hansson and
Stroebe (2007) emphasized how their integrative risk
factor framework allows for better prediction of
late-life bereavement outcome. Their framework
takes into account changes in social roles, physical
functioning, cognitive functioning, social support, etc.
that are often associated with aging. Older adults with
long mental health histories and multiple previous
losses may be at considerable risk for experiencing CG
and/or an exacerbation of existing psychological
problems. Our framework builds on Hansson and
Stroebe’s previous work by emphasizing the consider-
ation of pre-loss conditions. We hope that future
research will extend the work on validating CG to be
relevant to diverse groups of older adults, such that
cultural and other contextual factors can be used to
identify individuals at risk for negative outcomes and
in need of intervention.
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