IMPORTANCE: Prolonged grief disorder (PGD) is a potentially disabling condition that affects approximately 10% of bereaved people. Grief-focused cognitive behavior therapy (CBT) has been shown to be effective in treating PGD. Although treatments for PGD have focused on exposure therapy, much debate remains about whether exposure therapy is optimal for PGD. OBJECTIVE: To determine the relative efficacies of CBT with exposure therapy (CBT/exposure) or CBT alone for PGD. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial of 80 patients with PGD attending the outpatient University of New South Wales Traumatic Stress Clinic from September 17, 2007, through June 7, 2010. INTERVENTIONS: All patients received 10 weekly 2-hour group therapy sessions that consisted of CBT techniques. Patients also received 4 individual sessions, in which they were randomized to receive exposure therapy for memories of the death or supportive counseling. MAIN OUTCOMES AND MEASURES: Measures of PGD by clinical interview and self-reported measures of depression, cognitive appraisals, and functioning at the 6-month follow-up. RESULTS: Intention-to-treat analyses at follow-up indicated a significant quadratic time×treatment condition interaction effect (B [SE], 0.49 [0.16]; t120.16=3.08 [95% CI, 0.18-0.81]; P=.003), indicating that CBT/exposure led to greater PGD reductions than CBT alone. At follow-up, CBT/exposure led to greater reductions in depression (B [SE], 0.35 [0.12]; t112.65=2.83 [95% CI, 0.11-0.60]; P=.005), negative appraisals (B [SE], 0.68 [0.25]; t109.98=2.66 [95% CI, 0.17-1.18]; P=.009), and functional impairment (B [SE], 0.24 [0.08]; t111.40=3.01 [95% CI, 0.08-0.40]; P=.003) than CBT alone. In terms of treatment completers, fewer patients in the CBT/exposure condition at follow-up (14.8%) met criteria for PGD than those in the CBT condition (37.9%) (odds ratio, 3.51; 95% CI, 0.96-12.89; χ2=3.81; P=.04). CONCLUSIONS AND RELEVANCE: Including exposure therapy that promotes emotional processing of memories of the death is an important component to achieve optimal reductions in PGD severity. Facilitating emotional responses to the death may promote greater changes in appraisals about the loss, which are associated with symptom reduction. Promotion of emotional processing techniques in therapies to treat patients with PGD is needed. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12609000229279.
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