Complicated Grief Therapy and the COVID-19 Pandemic: A Systematic Literature Review

The advent of specialized grief treatments has led to the novel intervention of Complicated Grief Therapy (CGT) to treat maladaptive rumination and counterfactual thinking related to Prolonged Grief Disorder (PGD). This study reviewed the treatment modality and highlighted the benefits of CGT for grief-stricken adults who lost their loved ones to COVID-19 by analyzing the main studies published in selected databases for the last four years since COVID-19. Relevant publications were identified via electronic searches of two main databases Web of Science and SCOPUS along with five supporting databases according to the PRISMA guideline. 147 articles, 57 from PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Pubmed, and 90 from Web of Science and SCOPUS, were included. The seven studies that met the criteria showed that CGT is an effective measure to cope with complicated grief during the pandemic. In conclusion, this study contributes by expanding our understanding of CGT and highlighting the benefits. This study provides an effective treatment solution and healing for people afflicted with grief and may serve as a novel treatment for family members during the pandemic.

In 2019, the coronavirus (COVID-19) was discovered and emerged as one of the most widespread global pandemics that have occurred in the past century. The World Health Organization (WHO) classified Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) as a respiratory infection, and declared it a worldwide emergency due to its rapid spread (de Brito et al., 2022). Consequently, the situation exerted additional stressors in the community like isolation, quarantine, Intensive Care Unit (ICU) stresses, and unemployment (Pizzagoni, 2022). With regards to psychological stresses associated with this pandemic, three types have been identified. Firstly, the stress that lower income group may encounter from being made redundant which could result in depression, aggression, anxiety, and panic attacks. Secondly, the trauma faced by those who suffered from the virus and were in ICU, battling with death and have survived. Thirdly, the trauma of mourner’s who lost their loved ones to COVID-19 (Spoorthy et al., 2020). The tragic death of loved ones during this period of stress and pandemic COVID-19 means people are susceptible to experience a pervasive sense of loss and grief. COVID-19 has caused a huge emotional disruption rendering some individuals inflicted by the virus to unusual and sudden departure (Blake et al., 2020; Choi et al., 2022). COVID-19 has caused lasting ‘grief’ such as losing a breadwinner and subsequently and making families fall into poverty. Thus, ‘grief’ is compounded due to the emotional and social impact of sudden death and loss. Losing a breadwinner is an additional stress as the family loses the key figure that provides security making grief more complicated(Treglia et al., 2022). Prolonged grief can be classified as a disorder when symptoms of persistent disbelief and denial continue for at least six months to the extent of functional impairment along with intensified pain, longingness, and yearning (Shear & Shair, 2005a).

Doka and Aber (1989) identified a category of complicated grief known as ‘Disenfranchised Grief,’ which includes loss that cannot be openly acknowledged. The author has also introduced ‘grieving rules,’ which means a socially conferred right to grieve which permits individuals to mourn by knowing the limits of whom, when and why they are mourning over theloss (Corr, 1999). These rules give the right to family members to grieve over the loss of other family members. However, in some cases, a person incurs a loss but is deprived to mourn over the loss publicly which subsequently initiates grief (Corr, 1999). Besides the emotional aspect, complicated grief also includes understanding the physical, cognitive, social, and spiritual elements of grief (Doka, 1999). Losing a loved one to COVID-19 differs from ‘normal’ grieving due to the nature of death that is sudden and unexpected.  Furthermore, it is likely that there would have been prolong separation between family members when a member is diagnosed and quarantined. Thus, COVID-19 presents grieving rituals that are abrupt, particularly in relation to mourning, saying goodbyes and paying their final respect to the deceased. Furthermore, the families who were unable to attend the funeral of the loved ones further exacerbate grief. This potentially expedites stress, and emotional pressure on those who have unexpectedly lost their loved ones. In COVID-19, the traditional grief rituals are missing such as saying goodbyes, seeing their loved ones prior to burial or missing the actual burial, or funeralitself (Clark & Franzmann, 2006; Mitima-Verloop et al., 2020).

To date, the lack of historical work on complicated grief due to SARS, MERS or any other viral outbreaks is likely due to lack of recognition of prolonged grief disorder in the Diagnostic and Classification System (DSM), despite a debate to consider CG in the DSM since 2003 (Lichtenthal et al., 2004; Ott, 2003). The struggle for complicated grief to be recognized as a disorder was finally acknowledged in Diagnostic and Classification System (Boelen & Prigerson, 2013). Recently, a proper disorder relating to complicated grief was included in the International Classification of Diseases (ICD) (11 ed.; World Health Organization, 2018) and in the Diagnostic and Statistical Manual of Mental Disorders(5th ed., text rev.; American Psychiatric Association, 2023) to enable healthcare providers to distinguish between this kind of prolonged, complicated grief and normal grief using a common criterion which has led it to be included as a mental disorder as Prolonged Grief Disorder (PGD) (Prigerson et al., 2021). The ICD-11, which was released in 2018, included a diagnosis called Prolonged Grief Disorder (PGD) within the section on Disorders Specifically Associated with Stress. DSM-5-TR used the term Persistent Complex Bereavement Disorder (PCBD) while the ICD-11 used Prolonged Grief Disorder (PGD). The specific criteria for PCBD and PGD may have some variations in terms of symptomatology and duration, but they share the core idea of prolonged grief reactions.

Dual Process Model of Complicated Grief

Due to losing an attachment figure, an individual feels incredulity or disbelief with sorrowful emotions, yearning, longing, and intrusive thoughts for the deceased. With the successful process of mourning, the acute state transits towards the integration of grief within the mind, resulting in acceptance of loss. Trauma is resolved through the utilization of the "dual process model," which involves engaging in both loss-focused and restoration-focused activities (Shear & Shair, 2005b). However, in complicated grief, this resolution is derailed, and an individual’s normal functioning is disrupted (Shear, 2010). Specifically, failing to acknowledge and accept losing an important attachment figure to an abrupt death due to COVID-19; potentially leads to denial and can distance the person from other people and friends. Hence, one way to repair alliance due to attachment loss entails a successful resolution of grieving through loss and restoration-focused techniques referred to as ‘Dual Process Model of Coping with Bereavement.’ This technique is the basic principle underlying Complicated Grief Therapy (CGT) where it helps a person to accept loss. Loss-related procedures involve important steps that include:

i) imaginal revisiting in which the patient narrates when s/he first learned of the death; ii) working with memories and pictures; and
iii) situational revisiting. Restoration-focused procedures involve
i) working with aspirations and goals; ii) rewards and self-care and iii) situational revisiting. The aim is to move between loss-oriented and restoration-oriented activities (Stroebe & Schut, 1999, 2006, 2010) through which, the therapists review the individual's overall functioning and the impact of prolonged grief on daily life.

Complicated Grief During COVID-19

Even though the immediate crisis of COVID-19 has passed, the long-term effects on mental health specifically those related to grief and loss persist. The pandemic resulted in profound and widespread losses (Gopez, 2021; Hamid & Jahangir, 2022; Kumar & Nayar, 2021; Neimeyer & Lee, 2022; Ramadas & Vijayakumar, 2021; Sirrine et al., 2021) including losing loved ones (Albuquerque & Santos, 2021; Araujo Hernández et al., 2021; Gao et al., 2021; Guité-Verret et al., 2021; Katz et al., 2021; Liu et al., 2020; Matsuda et al., 2021; Menichetti Delor et al., 2021; Mfoafo-M’Carthy, 2021; Mortazavi et al., 2021), losing jobs (Rodriguez-Cuevas et al., 2021), losing physical as well as mental health (Allwood & Bell, 2020; Bhutani & Greenwald, 2021; Ione, 2021), and other losses such as economic downturn (Brenner & Bhugra, 2020; Spiro et al., 2021). Most of the COVID-19 research studies relate to issues arising from the pandemic itself spanning from economic downturn to mental health issues. While the immediate threat of COVID-19 has ended, the need for CGT remains critical. The pandemic's long-lasting effects on mental health call for continued study and use of CGT in order to help people who are currently struggling with complicated grief and to strengthen their ability to endure resilience in the future.

Nonetheless, there were reports showing the work of traumatic grief treatment on complicated grief relating to COVID-19 (Reitsma et al., 2021; Ugwu & Nwankwo, 2020; Szuhany et al., 2021). Grief intervention effectiveness studies indicate that grief interventions should be tailored according to the needs, readiness for treatment, and the nature of loss for individuals undergoing loss (Neimeyer & Jordan, 2013; Zech et al., 2010). In terms of evolution, CGT uses strategies from Interpersonal Therapy (IPT) to develop social relationships and help solve any relationship disputes. Additionally, CGT stems from CBT’s concepts, particularly in processing emotion, reducing situational avoidance, and identifying psychological impediments to grief. CGT stemmed from Motivational Interviewing (MI) to help clients achieve closure from the loss they suffer and for therapists, to deal empathetically with the client. The evolution is depicted in Fig 1 below:

Figure 1: The Evolution of CBT, MI and CGT from Previous Years to Current Development

CGT is based on the fundamental idea that grieving is an adaptive process (Drenth et al., 2010). This therapy exploits a human's natural adaptation to overcome complicated grief symptoms involving traumatic reactions to a sudden death. CGT is reported to be an evidence-based approach (Shear & Shair, 2005a; Shear et al., 2014; Shear & Bloom 2017) for complicated grief conditions. It has been tested under three National Institute of Mental Health (NIMH) supported funding that included a 2005 first study, 2014 research focused on older persons, and a 2015 joint study (Shear & Shair, 2005b; Shear et al., 2014; Shear & Bloom, 2017). This paper aims to examine the literature on CGT and COVID-19 and to narrow the gap as to date very limited studies have been conducted to show the effectiveness or impact of CGT on population rendered vulnerable due to COVID-19.

Empirical Evidence of CGT

The efficacy of CGT has been demonstrated in various studies (Grassi et al., 2018; Harris & Abrams, 2022; Lechner-Meichsner et al., 2022; Pontiggia et al., 2021; Roy, 2001; Skritskaya et al., 2020; Zisook & Shuchter, 2001) in dealing with grief related to suicide (Ali & Rehna, 2023; Pontiggia et al., 2021), accidents (Doka, 2014; Dyregrov et al., 2003; Miyabayashi & Yasuda, 2007), and natural disasters (Ekanayake et al., 2013; Rafiq & Blaschke, 2012a). Effective therapeutic interventions are imperative in light of Pakistan's high death toll and disruption of social practices, which have exacerbated mental health issues (Rafiq & Blaschke, 2012b). There is a noticeable research gap concerning the use of CGT in Pakistan during the pandemic, despite the benefits of the technique being well documented. There is empirical evidence for the mental health challenges faced by Pakistanis during the pandemic and underscore the urgent need for targeted interventions like CGT (Siddiqua et al., 2023). The individuals in Pakistan going through prolonged grieving can receive vital assistance through this therapy, if this gap is filled by research that is culturally appropriate.

Shear et al., (2005a) measured the effectiveness of CGT by comparing it with standard IPT for the treatment of complicated grief on 833 outpatients with 45 patients receiving 16 sessions in each group. The response to treatment was identified as achieving a score of one or two on the interviewer-assessed Clinical Global Impression – Improvement scale. In the CGT group, the rate of response was higher at 51% when contrasted with the IPT group, which was at 28%. When looking at the impact of pharmacology on patients getting CGT, 42 percent of those who were not on antidepressants and nine percent of those who were taking medication dropped out. In the IPT group, however, 30% of those on medication and 23% of those not on medications withdrew from the research. CGT group had a greater rate of treatment responders than the IPT group, both in the intent-to-treat analysis (51 percent in CGT versus 28% in IPT, P=0.02) and among those who responded positively (66 percent in CGT versus 32 percent) (Simon et al., 2008).

Cultural adaptation of psychotherapeutic interventions is crucial for their success. Prior research has emphasized the significance of culturally adapted CGT to the customs and values of bereavement in many cultural contexts. The results from a study of CGT on grieved Japanese women due to death of their loved ones (Asukai et al., 2011) suggest that this treatment is not just restricted to western culture only. Furthermore, as per randomized trials (Shear & Shair, 2005b; Supiano & Luptak, 2014), CGT was considered effective in reducing symptoms of prolonged grief because this enables individuals to be in touch with their memories and deal with their losses simultaneously. There have been approximately 30,000 deaths in Pakistan as a result of COVID leaving families grieving deeply (National Institute of Health Pakistan, 2021). Owing to Pakistan's distinct cultural background and the substantial effects of COVID-19, a thorough analysis of the body of research on CGT's efficacy in this area is desperately needed. The creation of culturally sensitive treatments can be guided by the identification of research gaps provided by this review. The current systematic literature review aims to examine the evidence regarding CGT during COVID-19.

Method 

The method followed the PRISMA 2020 guidelines and statement which is Preferred Reporting Items (Page et al., 2021) (Table 1). The PRISMA is a widely accepted set of guidelines that provide a structured approach for conducting and reporting systematic reviews and meta-analyses in research. The PRISMA guidelines help ensure transparency, completeness, and methodological rigor in these types of studies (Moher et al., 2009). Following research question has been formulated by referring to the review protocol.

“Does the existing literature on CGT address how to reduce complicated grief during the COVID-19 pandemic?”

Ethical Permission

Ethical permission was granted to work on the study work by the ethics committee, National Bioethics Committee Islamabad under NBC-868 vide Ref: No.4-87/NBC-868/22/640.

Eligibility Criteria

The inclusion criteria encompassed only studies about Complicated Grief Therapy during COVID-19; particularly research articles, randomized controlled trials, systematic reviews, and meta-analyses, case studies and commentaries. Only full text articles in English language are included. PhD theses, book series, books, chapters in books, conference proceedings and dissertations were excluded. Additionally, studies older than 2019 with no accessible data, title, or abstract were excluded.

Information Sources

The results of the review were obtained through the following databases: Web of Science, SCOPUS, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and PubMed. The studies from February 2020 (first death by COVID-19) to 10 December 2022 were included in database search. This was ensured that the literature reviewed included studies developed according to the current pandemic context.

Search Strategy

Identification is a process to search for studies that are relevant to the review protocol with synonyms, related and varied terms with main keywords of ‘loss, complicated grief, bereavement, or trauma along with pandemic, epidemic, or/and COVID-19’. The designed retrieval strategy employed the use of operators 'AND' and 'OR' for conducting the search in this review. Medical Subject Headings (MeSH) terms were used when applicable. A variety of search terms used were as follows: ‘Complicated grief therapy, grief, grief therapy, loss, COVID-19, mental health’. Specific keywords that were input in each database are presented in Table 1.

Table 1: Specific Keywords for Input in Each Database

Data Collection Process

A systematic literature review was conducted through SCOPUS, Web of Science (WOS), PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and PubMed databases to evaluate studies on CGT in adults who lost their loved ones to COVID-19. Firstly, keyword searches (refer to Table 1) were conducted from the databases, resulting in 147 articles. After removal of duplicates, 54 articles were identified and then through reviewing the abstracts and titles, 28 articles were selected. Finally, after reading and evaluating the full text of the manuscripts, the number of relevant articles was reduced to seven studies. Table 2 shows the information on the selection process of the relevant studies. Various combinations of keywords yielded a total of 147 articles, highlighting the search's thoroughness and variability in findings across different databases.

Table 2: Data Collection Process with Keywords

Note. AMED: Allied and Complementary Medicine Database, CENTRAL: Cochrane Central Register of Controlled Trials, WOS: Web of Science.

Results

Study Selection

The citation was managed using Mendeley and duplicates were identified and eliminated from the dataset. To expand the search, the reference lists of relevant studies were examined, leading to the identification of additional studies. The remaining records were initially screened based on their titles and abstracts, with preset inclusion and exclusion criteria applied to assess their eligibility for the review. Unsuitable papers were excluded, and the full-text versions of the remaining papers were acquired for additional assessment against the eligibility criteria. Through this rigorous screening process, the final evaluation included the papers that met the eligibility criteria, as illustrated in Figure 2:

Figure 2: PrismaFlow Diagram

Adapted from the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines presented in (Moher et al., 2010).

Study Characteristics

The selected studies are published in peer-reviewed journals. The final result yielded seven studies (refer to Table 3), published from 2019 to 2022 (Colvin & Ceide, 2021; Diolaiuti et al., 2021; Bradley et al., 2021; Goveas & Shear, 2021; Ishikawa, 2020; Kaur-Aujla et al., 2022; Na et al., 2019). Due to a shortage of CGT literature during the COVID-19 pandemic, all available studies mentioning CGT and showing the role CGT plays in mitigating grief during post pandemic and in the endemic stage have been included.

According to Neimeyer (2013), meaning making is important in bereavement and helps in adjusting to new relationships. A study was conducted to explore the utilization of expressive counselling techniques on a client. It further elaborated the available clinical counselling resources of CGT featuring loss and restoration, and the concept of meaning-making for bereaved people during COVID-19 (Bradley et al., 2021). In a commentary, the new diagnosis of Prolonged Grief Disorder (PGD) was reviewed, and anticipated a high rate of PGD in the time of COVID-19. In the similar context, complicated grief was identified by Iglewicz et al. (2020) within this bereavement, and CGT was presented as a unique concept of loss and restoration procedures. Loss focused element presented the concept of acceptance of reality of loss, whereas the restoration-focused element envisioned the evolving world with a new cognitive and emotional state (Iglewicz et al., 2020).

Goveas and Shear (2021) discuss the new diagnosis of Prolonged Grief Disorder (PGD), which highlights a high rate of PGD during the COVID-19 pandemic. Mental problems related to grieving are also expected to rise prolonged grief symptoms. The authors outlined Prolonged Grief Disorder risk factors associated to mortality during COVID-19, which included the events, context, and repercussions of the death. Thus, this study recommends CGT as the first line of treatment for managing PGD (Goveas & Shear, 2021). PGD is likely to be more common in those who are older and have a mental history, much as COVID-19 vulnerability is higher in the elderly and those with chronic illness. If a loved one falls into one of these susceptible groups, family members should be encouraged to keep a careful eye on them. They also suggest coping and resilience strategies to mitigate complicated grief via online self-help and Complicated Grief Therapy specifically in older persons. Grief-specific treatments like CGT are more targeted than depression-specific treatments.

Colvin and Ceide (2021) stressed that diagnosing and identifying Prolonged Grief Disorder (PGD) and Major Depressive Disorder (MDD) is important so that among older adults’ specific pharmacological interventions or psychotherapies may be addressed. Additionally, specific psychotherapy among present grief interventions such as CBT, Meaning-Centred Grief Therapy (MCGT), IPT, CGT, Life Review Therapy (LRT), Integrative Testimonial Therapy (ITT) and Specific PTSD-Related Treatments may be administered as per diagnosis (Colvin & Ceide, 2021). In conclusion, according to the literature review, no therapy stands out as superior to others. Instead, treatment should prioritize the individual needs of those with grief disorders.

Clarke (2021) identified different grieving styles post COVID-19 which include historical models of grief such as psychoanalytic (Freud & Hall, 1921), phase theory of grief (Lindemann, 1944), attachment theory (Bowlby, 1969), Kübler-Ross’ five stages of grief (Kübler-Ross & Kessler, 2005), contemporary models of grief like task-based models (Worden, 1983), dual process model (Stroebe & Schut, 1999) and continuing bonds (Klass, 2006). He also discussed the prevalence of complicated grief and its comorbidities in children and the elderly during COVID-19. He proposed different grief interventions such as CBT, Multidimensional grief therapy (MGT), and CGT based on models of complicated grief which can be administered with regards to COVID-19. CGT was found as an effective treatment, superior to depression-focused treatments (Iglewicz et al., 2020) and interpersonal therapy (Shear & Shair, 2005a).

Pharmacotherapy may benefit the completion of CGT as it may help patients tolerate the emotional pain that grief psychotherapy arouses as evidenced by another study (91% CGT with antidepressants vs. 58% CGT alone) (Simon et al., 2008).
 Kaur-Aujla et al., (2022) defined non-death related loss and grieving as ambiguous loss and disenfranchised grief to death related loss as idiosyncratic loss. The therapeutic process depends on different therapeutic options available such as CGT, CBT, and DBT during COVID-19. Firstly, CBT was recognized as a suitable therapy for addressing grief (Matthews & Marwit, 2004). The application of CBT in COVID-19 situations; however, the longevity of the treatment became an issue. Thus, Kaur-Aujla et al., (2022) defined the proposal of Shear and Shair (2005b) regarding a 16-session module of CGT which has shown to be an effective targeted strategy for combating complicated grief symptoms related to COVID-19. Ishikawa (2020) gave the concept of supporting older adults with anticipated grief who struggle with loneliness and fear of death by using several different strategies ensured better coping outcomes/ results during COVID-19. One of the strategies is to introduce psychological first aid to support older adults. However, for death-related grief, CGT appears to be more effective as it revisits techniques which enhance coping skills (Ishikawa, 2020). Diolaiuti et al., (2021) explained in their study that to create effective intervention strategies, the identification of risk factors and protective factors against the onset of Complicated Grief (CG) and CGD is essential. This study also analysed prevention strategies including Acceptance and Commitment Therapy, Accelerated Resolution Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and CGT (Diolaiuti et al., 2021). Table 3 shows the information of the relevant selected studies in detail.

Table 3: Information of the Relevant Selected Studies

Discussion

Based on our findings, the two important studies stand out (Bradley et al., 2021) briefly described the case history of people with complicated grief and present current bereavement support strategies such as CBT, CGT, meaning-making and logotherapy; and Goveas and Shear (2020) which examined coping and resilience strategies such as online self-help and complicated grief therapy. Other notable studies have investigated the treatment options for complicated grief in older adults and found CGT as an effective treatment modality for grief  (Bradley et al., 2021; Clarke, 2021; Colvin & Ceide, 2021; Diolaiuti et al., 2021; Goveas & Shear, 2020; Ishikawa, 2020; Kaur-Aujla et al., 2022).

The majority of information regarding the potential effects of the pandemic on populations was already discussed and compiled during the later stages of the first two waves of the COVID-19 pandemic. At the time this review article was written; it was evident that the pandemic had reached an endemic stage. Nevertheless, grief can be a long-lasting factor for some individuals, which shows the need for practitioners and researchers to address post-pandemic issues. In these seven extracted articles, there are discussions regarding new ways to deal with losing a loved one to COVID-19 which is relevant to the new modalities and psychotherapies available. In our literature review, no modalities have been shown to be more superior.

In all selected publications, complicated grief therapy has been identified as an evidence-based strategy for stabilizing, exploring, and confronting the most painful parts of death and loss through specified techniques. Another finding from the extensive review is that for death-related grief in older adults, CGT appeared to be effective technique which strengthens the coping skills of individuals. It has demonstrated as an evidence-based protocol for mental health practitioners and significantly effective for complicated grief compared to proven efficacious treatments for depression, such as citalopram (Shear et al., 2016)and interpersonal therapy (Shear & Shair, 2005a; Shear et al., 2014).

The aim of this review is to summarize current evidence on the utilization of CGT and other therapeutic options available for treating complicated grief during COVID-19. With regards to the challenges of combating after grieving effects of COVID-19 deaths, the knowledge about therapeutic options particularly targeting complicated grief symptoms is an important first step for the development of effective strategies. As a result, this review utilized a narrative approach, qualitatively comparing various sorts of studies. There are many studies on complicated grief and COVID-19 (Bovero et al., 2022; Dashti et al., 2022; Downar et al., 2022; Eisma & Tamminga, 2022; Khoury et al., 2022; Mondal, 2022; Ostadhashemi et al., 2022; Rahmani et al., 2023) however, very few have investigated the use of CGT as an intervention option for people afflicted with complicated grief during COVID-19. Previous studies were focused on issues concerning grief and less on interventions. Researchers examined complicated grief as an issue rather works on treatment or intervention. Since CGT during COVID-19 is a relatively new area of interest, and to date no review has been conducted on CGT and COVID-19, more studies are expected to be published in the years to come. Future studies should focus on the effectiveness of CGT in helping individuals afflicted by grief due to the loss of a loved one post COVID. There is limited evidence in the literature because majority of material originates from qualitative studies and no quantitative or longitudinal studies are available. As a result, the existing literature primarily supports the significance of CGT as an evidence-based therapy for complicated grief and hence, could be considered as a treatment option used in conjunction with other interventions.
A significant drawback of included subjective studies in the current study is the lack of an objective analysis and absence of factual, verified information and quantitative data, which are essential for providing a comprehensive understanding of the subject matter. It is also noteworthy that none of the studies have incorporated a combination of objective and self-reported measures, which is recommended for assessing specific domains of CGT. While, the current evidence may be limited, it is considered reliable since it is based on the findings from high-quality studies.

Further implications of this review include different contexts, such as indigenous communities, where structural injustices and pre-existing vulnerabilities have frequently resulted in a disproportionately severe impact from COVID-19. A comprehensive approach is needed to integrate CGT in indigenous settings, taking into account the cultural, spiritual, and community activities that are integral to these communities. This can enhance the effectiveness of CGT and contribute to the overall well-being of these communities in the aftermath of COVID-19.

Conclusion

In conclusion, the findings of this analysis highlight the necessity to investigate the efficacy of CGT in communities afflicted by grief as a result of COVID-19. As we anticipate the potential challenges ahead, it is vital to recognize that untreated grief that can lead to severe complications. Acquiring knowledge about CGT is an essential initial step in developing effective strategies to address this condition, particularly in aging populations. It is worth mentioning that none of the studies examined provided a quantitative statistics and data analysis. Longitudinal and experimental approaches would be required to uncover suitable CGT strategies. The various settings in which CGT may occur necessitate more exploration. Design of future studies should include quantitative studies and mixed-method research to provide a more balanced and comprehensive approach in better understanding the effectiveness of CGT. Given the far-reaching effects of COVID-19 on a global scale, crossing cultural barriers, it becomes imperative to acknowledge the significance of cultural norms when dealing with therapies centred around grief and hence it is crucial to consider cultural norms when addressing grief-based therapies.

References

Albuquerque, S., & Santos, A. R. (2021). “In the Same Storm, but Not on the Same Boat”: Children Grief During the COVID-19 Pandemic. Frontiers in Psychiatry, 12. http://doi.org/10.3389/fpsyt.2021.638866

Ali, U., &Rehna, T. (2023). Grief Reactions and Suicide Bereavement in the Context of Stigma among Parents: An Interpretative Phenomenological Analysis. Annales Médico-Psychologiques, Revue Psychiatrique, 181(7), 598-603.

Allwood, L., & Bell, A. (2020). COVID-19: Understanding inequalities in mental health during the pandemic. Centre for Mental Health.

Araujo Hernández, M., García Navarro, S., & García-Navarro, E. B. (2021). Approaching grief and death in family members of patients with COVID-19: Narrative review. Enfermeria Clinica, 31. https://doi.org/10.1016/j.enfcli.2020.05.011

Asukai, N., Tsuruta, N., & Saito, A. (2011). Pilot study on traumatic grief treatment program for Japanese women bereaved by violent death. Journal of Traumatic Stress, 24(4), 470-473.

Bhutani, S., & Greenwald, B. (2021). Loneliness in the Elderly During the COVID-19 Pandemic: A Literature Review in Preparation for a Future Study. The American Journal of Geriatric Psychiatry, 29(4). http://doi.org/10.1016/j.jagp.2021.01.081

Blake, H., Bermingham, F., Johnson, G., & Tabner, A. (2020). Mitigating the psychological impact of COVID-19 on healthcare workers: A digital learning package. International Journal of Environmental Research and Public Health, 17(9), 2997.

Boelen, P. A., & Prigerson, H. G. (2013). Prolonged grief disorder as a new diagnostic category in DSM-5. In Complicated Grief: Scientific Foundations for Health Care Professionals. http://doi.org/10.4324/9780203105115

Bovero, A., Pidinchedda, A., Clovis, F., Berchialla, P., & Carletto, S. (2022). Psychosocial factors associated with complicated grief in caregivers during COVID-19: Results from a preliminary cross-sectional study. Death Studies, 46(6). https://doi.org/10.1080/07481187.2021.2019144

Bowlby, J. (1969). In J. Bowlby. Attachment and Loss, 1.

Bradley, L., Hendricks, B., Noble, N., & Fox, T. (2021). COVID-19: Counseling with Bereaved Parents. Family Journal, 29(3).

Brenner, M. H., & Bhugra, D. (2020). Acceleration of Anxiety, Depression, and Suicide: Secondary Effects of Economic Disruption Related to COVID-19. Frontiers in Psychiatry, 11.

Choi, Y. J., Kühner, S., & Shi, S. J. (2022). From “new social risks” to “COVID social risks”: The challenges for inclusive society in South Korea, Hong Kong, and Taiwan Amid the pandemic. Policy and Society.

Clark, J., & Franzmann, M. (2006). Authority from grief, presence and place in the making of roadside memorials. Death Studies, 30(6), 579-599.

Clarke, J. (2021). What Makes Grief Complicated? A Review. In Australian Counselling Research.

Colvin, C., & Ceide, M. (2021). Review of Grief Therapies for Older Adults. In Current Geriatrics Reports (Vol. 10, Issue 3). http://doi.org/10.1007/s13670-021-00362-w

Corr, C. A. (1999). Enhancing the concept of disenfranchised grief. OMEGA-Journal of Death and Dying, 38(1), 1-20.

Dashti, S., Najafi, T. F., Mohammadzadeh, F., Kalat, A. R., & Bahri, N. (2022). Knowledge Level of Health Care Providers about Complicated Grief during the COVID-19 Pandemic. Iranian Journal of Psychiatry, 17(2). https://doi.org/10.18502/ijps.v17i2.8905

De Brito, L. O., Nunez, S. C., Navarro, R. S., & Cogo, J. C. (2022). COVID-19: Analysis of Personal Protective Equipment Costs in the First Quarter of 2020 at a Philanthropic Hospital in Southern Bahia-Brazil. Brazilian Congress on Biomedical Engineering, 2169-2172.

Diolaiuti, F., Marazziti, D., Beatino, M. F., Mucci, F., & Pozza, A. (2021). Impact and consequences of COVID-19 pandemic on complicated grief and persistent complex bereavement disorder. Psychiatry Research, 300, 113916.

Doka, K. J. (1999). Disenfranchised grief. Bereavement Care, 18(3), 37-39.

Doka, K. J. (2014). Living with grief: After sudden loss suicide, homicide, accident, heart attack, stroke. Taylor & Francis.

Doka, K. J., & Aber, R. (1989). Psychosocial loss and grief. Disenfranchised Grief: Recognizing Hidden Sorrow, 187-198.

Downar, J., Parsons, H. A., Cohen, L., Besserer, E., Adeli, S., Gratton, V., Murphy, R., Warmels, G., Bruni, A., Bhimji, K., Dyason, C., Enright, P., Desjardins, I., Wooller, K., Kabir, M., Noel, C., Heidinger, B., Anderson, K., Arsenault-Mehta, K., … &Lawlor, P. (2022). Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study. Palliative Medicine, 36(8). https://doi.org/10.1177/026921632211097

DSM-5-TR. (2023). American Psychiatric Association. Manual diagnostic estatístico de transtornosmentais. In Psychopathology: Foundations for a Contemporary Understanding: Fifth Edition.

Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of psychosocial distress after suicide, SIDS and accidents. Death Studies, 27(2), 143-165.

Eisma, M. C., & Tamminga, A. (2022). COVID-19, natural, and unnatural bereavement: Comprehensive comparisons of loss circumstances and grief severity. In European Journal of Psych traumatology,13(1). http://doi.org/10.1080/20008198.2022.2062998

Ekanayake, S., Prince, M., Sumathipala, A., Siribaddana, S., & Morgan, C. (2013). “We lost all we had in a second”: Coping with grief and loss after a natural disaster. World Psychiatry, 12(1), 69-75. http://doi.org/10.1002/wps.20018

Freud, S., & Hall, G. S. (1921). A General Introduction to Psychoanalysis. Southern Medical Journal, 14(4).

Gao, X., Wang, Z., Kong, C., Fan, H., Zhang, J., Wang, J., Tan, L., & Wang, J. (2021). A Cross-Sectional Survey to Assess Health Care Workers’ Grief Counseling for Bereaved Families of COVID-19 Victims in Wuhan, China. Disaster Medicine and Public Health Preparedness. http://doi.org/10.1017/dmp.2021.132

Gopez, J. M. W. (2021). Correspondence: Hope as fundamental human response to loss and grief experiences in the time of COVID-19. Journal of Public Health (United Kingdom), 43(2). https://doi.org/10.1093/pub med/fdab042

Goveas, J. S., & Shear, M. K. (2020). Grief and the COVID-19 Pandemic in Older Adults. American Journal of Geriatric Psychiatry, 28(10). http://doi.org/10.1016/j.jagp.2020.06.021

Goveas, J. S., & Shear, M. K. (2021). Grief and the COVID-19 Pandemic in Older Adults. FOCUS, 19(3). https://doi.org/10.1176/appi.focus.19303

Grassi, L., Nanni, M. G., & Caruso, R. (2018). Psychotherapeutic interventions. In Psychosocial Issues in Palliative Care: A Community Based Approach For Life Limiting Illness. https://doi.org/10.1093/oso/9780198806677.003.0010

Guité-Verret, A., Vachon, M., Ummel, D., Lessard, E., & Francoeur-Carron, C. (2021). Expressing grief through metaphors: Family caregivers’ experience of care and grief during the Covid-19 pandemic. International Journal of Qualitative Studies on Health and Well-Being, 16(1). https://doi.org/10.1080/17482631.2021.1996872

Hamid, W., & Jahangir, M. S. (2022). Dying, Death and Mourning amid COVID-19 Pandemic in Kashmir: A Qualitative Study. Omega (United States), 85(3). https://doi.org/10.1177/0030222820953708

Harris, H. L., & Abrams, L. P. (2022). Addiction and Grief in the Military. In Grief Work in Addictions Counseling. http://doi.org/10.4324/9781003106906-12

Iglewicz, A., Shear, M. K., Reynolds, C. F., Simon, N., Lebowitz, B., & Zisook, S. (2020). Complicated grief therapy for clinicians: An evidence-based protocol for mental health practice. In Depression and Anxiety,37(1). https://doi.org/10.1002/da.22965

Ione, A. (2021). Dementia grief reconceptualized: Systemic review of psychotherapeutic approaches for BPSD and NPS during COVID-19. Alzheimer’s & Dementia : The Journal of the Alzheimer’s Association, 17. https://doi.org/10.1002/alz.056678

Ishikawa, R. Z. (2020). I may never see the ocean again: Loss and grief among older adults during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12. https://doi.org/10.1037/tra0000695

Katz, N. T., McInerney, M., Ravindran, G., & Gold, M. (2021). Silent suffering of the dying and their families: Impact of COVID-19. In Internal Medicine Journal, 51(3). http://doi.org/10.1111/imj.15101

Kaur-Aujla, H., Lillie, K., & Wagstaff, C. (2022). Prognosticating COVID Therapeutic Responses: Ambiguous Loss and Disenfranchised Grief. In Frontiers in Public Health,10, Frontiers Media S.A. http://doi.org/10.3389/fpubh.2022.799593

Khoury, B., Barbarin, O., Gutiérrez, G., Klicperova-Baker, M., Padakannaya, P., & Thompson, A. (2022). Complicated grief during COVID-19: An international perspective. International Perspectives in Psychology: Research, Practice, Consultation, 11.

Klass, D. (2006). Continuing conversation about continuing bonds. Death Studies, 30(9), 843-858.

Kübler-Ross, E., & Kessler, D. (2005). On grief and grieving: Finding the meaning of grief through the five stages of loss. Simon and Schuster.

Kumar, A., & Nayar, K. R. (2021). COVID 19 and its mental health consequences. In Journal of Mental Health, 30(1), 1-2. Taylor & Francis.

Lechner-Meichsner, F., Mauro, C., Skritskaya, N. A., & Shear, M. K. (2022). Change in avoidance and negative grief-related cognitions mediates treatment outcome in older adults with prolonged grief disorder. Psychotherapy Research, 32(1). http://doi.org/10.1080/10503307.2021.1909769

Lichtenthal, W. G., Cruess, D. G., & Prigerson, H. G. (2004). A case for establishing complicated grief as a distinct mental disorder in DSM-V. Clinical Psychology Review, 24(6), 637-662.

Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101(2), 141-148.

Liu, S., Liu, Y., & Liu, Y. (2020). Somatic symptoms and concern regarding COVID-19 among Chinese college and primary school students: A cross-sectional survey. Psychiatry Research, 289. https://doi.org/10.1016/j.psychres.2020.113070

Matsuda, Y., Takebayashi, Y., Nakajima, S., & Ito, M. (2021). Managing Grief of Bereaved Families During the COVID-19 Pandemic in Japan. Frontiers in Psychiatry, 12. http://doi.org/10.3389/fpsyt.2021.637237

Matthews, L. T., & Marwit, S. J. (2004). Complicated grief and the trend toward cognitive-behavioral therapy. Death Studies, 28(9), 849-863. http://doi.org/10.1080/07481180490490924

Menichetti Delor, J. P., Borghi, L., Cao di San Marco, E., Fossati, I., &Vegni, E. (2021). Phone follow up to families of COVID-19 patients who died at the hospital: Families’ grief reactions and clinical psychologists’ roles. International Journal of Psychology, 56(4). http://doi.org/10.1002/ijop.12742

Mfoafo-M’Carthy, M. (2021). Mama! I hear your silence: Grief and COVID-19 on the Global North and South disparity. Qualitative Social Work, 20(1-2). http://doi.org/10.1177/1473325020973303

Mitima-Verloop, H. B., Boelen, P. A., & Mooren, T. T. M. (2020). Commemoration of disruptive events: A scoping review about posttraumatic stress reactions and related factors. In European Journal of PsychoTraumatology, 11(1). http://doi.org/10.1080/20008198.2019.1701226

Miyabayashi, S., & Yasuda, J. (2007). Effects of loss from suicide, accidents, acute illness and chronic illness on bereaved spouses and parents in Japan: Their general health, depressive mood, and grief reaction. Psychiatry and Clinical Neurosciences, 61(5), 502-508.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Group, P. (2010). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. International Journal of Surgery, 8(5), 336-341.

Moher, D., Tetzlaff, J., & Altman, D., G, L. A. (2009). PRISMA 2009 Flow Diagram. In The PRISMA statement, 6.

Mondal, S. (2022). Living in a Limbo: A Sociological Study of Missing Funerals, Death Rituals, and Complicated Grief in COVID-19. Illness Crisis and Loss. https://doi.org/10.1177/10541373221131760

Mortazavi, S. S., Shahbazi, N., Taban, M., Alimohammadi, A., & Shati, M. (2021). Mourning During Corona: A Phenomenological Study of Grief Experience Among Close Relatives During COVID-19 Pandemics. Omega (United States). https://doi.org/10.1177/00302228211032736

National Institute of Health Pakistan. (2021). COVID-19 Statistics. https://www.nih.org.pk/

Neimeyer, R. A. (2013). The staging of grief: Toward an active model of mourning. In Studies of Grief and Bereavement.

Neimeyer, R. A., & Jordan, J. R. (2013). Historical and contemporary perspectives on assessment and intervention. In Handbook of thanatology,247-266. Routledge.

Neimeyer, R. A., & Lee, S. A. (2022). Circumstances of the death and associated risk factors for severity and impairment of COVID-19 grief. Death Studies, 46(1). http://doi.org/10.1080/07481187.2021.1896459

Ostadhashemi, L., Alipour, F., Ahmadi, S., Khoshnami, M. S., Arshi, M., & Hossein Javadi, S. M. (2022). Complicated Grief: The Lived Experiences of Those Bereaved By COVID-19. Omega (United States). http://doi.org/10.1177/00302228221111931

Ott, C. H. (2003). The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27(3), 249-272.

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., …& Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. In The BMJ, 372. http://doi.org/10.1136/bmj.n71

Pizzagoni, T. (2022). A Focus for Recovery: Creative Dance Movement in the Healing of Mental Stress Caused by the COVID-19 Pandemic. Mills College.

Pontiggia, M., Di Pierro, R., Madeddu, F., & Calati, R. (2021). Surviving the suicide of a loved one: Impact and postvention. In RecentiProgressi in Medicina, 112(11). http://doi.org/10.1701/3696.36851

Prigerson, H. G., Kakarala, S., Gang, J., & Maciejewski, P. K. (2021). History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis. In Annual Review of Clinical Psychology, 17, https://doi.org/10.1146/annurev-clinpsy-081219-093600

Rafiq, L., & Blaschke, T. (2012a). Disaster risk and vulnerability in Pakistan at a district level. Geomatics, Natural Hazards and Risk, 3(4), 324-341. https://doi.org/10.1080/19475705.2011.626083

Rafiq, L., & Blaschke, T. (2012b). Disaster risk and vulnerability in Pakistan at a district level. Geomatics, Natural Hazards and Risk, 3(4), 324-341.

Rahmani, F., Hosseinzadeh, M., & Gholizadeh, L. (2023). Complicated grief and related factors among nursing staff during the Covid-19 pandemic: A cross-sectional study. BMC Psychiatry, 23(1). http://doi.org/10.1186/s12888-023-04562-w

Ramadas, S., & Vijayakumar, S. (2021). Disenfranchised grief and Covid-19: How do we make it less painful? Indian Journal of Medical Ethics, VI(2). http://doi.org/10.20529/IJME.2020.128

Reitsma, L., Boelen, P. A., de Keijser, J., & Lenferink, L. I. M. (2021). Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: Study protocol for a randomized controlled trial and a controlled trial. European Journal of Psychotraumatology, 12(1). http://doi.org/10.1080/20008198.2021.1987687

Rodriguez-Cuevas, F., Valtierra-Gutiérrez, E., Roblero-Castro, J., & Guzmán-Roblero, C. (2021). Living Six Hours Away from Mental Health Specialists: Enabling Access to Psychosocial Mental Health Services through the Implementation of Problem Management plus Delivered by Community Health Workers in Rural Chiapas, Mexico. Intervention, 19(1). http://doi.org/10.4103/INTV.INTV2820

Roy, R. (2001). Old age, pain, and loss. Topics in Geriatric Rehabilitation, 16(3). http://doi.org/10.1097/00013614-200103000-00009

Shear, K., & Shair, H. (2005a). Attachment, loss, and complicated grief. Developmental Psychobiology: The Journal of the International Society for Developmental Psychobiology, 47(3), 253-267.

Shear, K., & Shair, H. (2005b). Attachment, loss, and complicated grief. Developmental Psychobiology: The Journal of the International Society for Developmental Psychobiology, 47(3), 253-267.

Shear, M. K. (2010). Complicated grief treatment: The theory, practice and outcomes. Bereavement Care, 29(3), 10-14.

Shear, M. K., Reynolds, C. F., Simon, N. M., Zisook, S., Wang, Y., Mauro, C., Duan, N., Lebowitz, B., & Skritskaya, N. (2016). Optimizing treatment of complicated grief a randomized clinical trial. JAMA Psychiatry, 73(7). http://doi.org/10.1001/jamapsychiatry.2016.0892

Shear, M. K., Wang, Y., Skritskaya, N., Duan, N., Mauro, C., & Ghesquiere, A. (2014). Treatment of complicated grief in elderly persons: A randomized clinical trial. JAMA Psychiatry, 71(11), 1287-1295.

Siddiqua, A., Ahmad, S., Nawaz, I., Zeeshan, M., & Rao, A. (2023). The Smoldering Pandemic: Self-Reported Prevalence Assessment of Prolonged Grief Disorder. A cross sectional study of bereaving adults during the Covid Pandemic in Pakistan. MedRxiv, 2021-2023.

Simon, N. M., Shear, M. K., Fagiolini, A., Frank, E., Zalta, A., Thompson, E. H., Reynolds III, C. F., & Silowash, R. (2008). Impact of concurrent naturalistic pharmacotherapy on psychotherapy of complicated grief. Psychiatry Research, 159(1-2), 31-36.

Sirrine, E. H., Kliner, O., & Gollery, T. J. (2021). College Student Experiences of Grief and Loss Amid the COVID-19 Global Pandemic. Omega (United States). https://doi.org/10.1177/00302228211027461

Skritskaya, N. A., Mauro, C., Garcia de la Garza, A., Meichsner, F., Lebowitz, B., Reynolds, C. F., Simon, N. M., Zisook, S., & Shear, M. K. (2020). Changes in typical beliefs in response to complicated grief treatment. Depression and Anxiety, 37(1), 81-89. http://doi.org/10.1002/da.22981

Spiro, N., Perkins, R., Kaye, S., Tymoszuk, U., Mason-Bertrand, A., Cossette, I., Glasser, S., & Williamon, A. (2021). The Effects of COVID-19 Lockdown 1.0 on Working Patterns, Income, and Wellbeing Among Performing Arts Professionals in the United Kingdom (April-June 2020). Frontiers in Psychology, 11. http://doi.org/10.3389/fpsyg.2020.594086

Spoorthy, M. S., Pratapa, S. K., & Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic–A review. Asian Journal of Psychiatry, 51, 102119.

Stella A. Ugwu, & Nwankwo, B. E. (2020). Modern Funeral Rites during COVID-19 Pandemic: The Socio-Psychological Implications. Nigerian Journal of Social Psychology, 3(1).

Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197-224. http://doi.org/10.1080/074811899201046

Stroebe, M., & Schut, H. (2006). Complicated grief: A conceptual analysis of the field. OMEGA-Journal of Death and Dying, 52(1), 53-70.

Stroebe, M., & Schut, H. (2010). The dual process model of coping with bereavement: A decade on. Omega: Journal of Death and Dying, 61(4). http://doi.org/10.2190/OM.61.4.b

Supiano, K. P., & Luptak, M. (2014). Complicated grief in older adults: A randomized controlled trial of complicated grief group therapy. The Gerontologist, 54(5), 840-856.

Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged Grief Disorder: Course, Diagnosis, Assessment, and Treatment. FOCUS, 19(2). http://doi.org/10.1176/appi.focus.20200052

Treglia, D., Cutuli, J. J., Arasteh, K., Bridgeland, J., Edson, G., Phillips, S., & Balakrishna, A. (2022). Hidden Pain: Children Who Lost a Parent or Caregiver to COVID-19 and What the Nation Can Do to Help Them.

Worden, J. W. (1983). A handbook for the mental health practitioner. Brunner-Routledge.

World Health Organisation. (2018). ICD-11 for Mortality and Morbidity Statistics (ICD-11 MMS) 2018 version. Https://Icd.Who.Int/Browse11/L-M/En.

Zech, E., Ryckebosch-Dayez, A.S., & Delespaux, E. (2010). Improving the efficacy of intervention for bereaved individuals: Toward a process-focused psychotherapeutic perspective. Psychological Belgica, 50(1-2).

Zisook, S., & Shuchter, S. R. (2001). Treatment of the Depressions of Bereavement. American Behavioral Scientist, 44(5). http://doi.org/10.1177/00027640121956494

Received 19October 2023
Revision received 04 August 2024