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Treating complicated grief and substance use disorders: A pilot study
Journal of Substance Abuse Treatment 30 (2006) 205 – 211
Treating complicated grief and substance use disorders: A pilot study Allan Zuckoff, (Ph.D.)4, Katherine Shear, (M.D.), Ellen Frank, (Ph.D.), Dennis C. Daley, (Ph.D.), Karen Seligman, (M.Ed.), Russell Silowash, (B.A.) Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213-2393, USA Received 13 May 2005; received in revised form 15 November 2005; accepted 8 December 2005
Abstract Empirically supported treatments for co-occurring substance use disorders (SUDs) and grief problems are lacking, despite the salience of grief pathology in substance abusers. Identification of a syndrome of complicated grief, distinct from bereavement-related depression and anxiety, led to the development of a targeted treatment, but this treatment has not been tried with persons with SUDs. We recruited 16 adults with complicated grief and substance dependence or abuse into an open pilot study of a manualized 24-session treatment, incorporating motivational interviewing and emotion coping and communication skills into our efficacious complicated grief treatment. Completer and intent-to-treat analyses showed significant reductions in Inventory of Complicated Grief and Beck Depression Inventory scores, with large effect sizes. Timeline Followback percent days abstinent increased significantly in both analyses, with medium to large effect sizes, and cravings declined significantly. Study limitations notwithstanding, complicated grief and substance use treatment appears to be a promising intervention that merits further research. D 2006 Elsevier Inc. All rights reserved. Keywords: Complicated grief; Substance abuse; Motivational interviewing; Exposure therapy; Emotion coping
1. Introduction Grief has long been recognized as salient in treating persons with substance use disorders (SUDs). Bellwood (1975) described addressing bunresolved grief Q as a key to successful alcoholism treatment, and Blankfield (1982/1983) found intense grief or significant bereavement in 20% of consecutive inpatient admissions to a substance abuse treatment center. Yet, despite numerous published clinical accounts of grief treatment in those who abuse or are dependent on substances, no controlled study in which grief-specific symptoms were defined or in which both
Portions of this work were presented at the 158th Annual Meeting of the American Psychiatric Association, Atlanta, GA, May 26, 2005; at the 67th Annual Scientific Meeting of the College on Problems of Drug Dependence, Orlando, FL, June 21, 2005; and at the 11th International Conference on Treatment of Addictive Behavior, Santa Fe, NM, February 1, 2006. 4 Corresponding author. Tel.: +1 412 246 5817; fax: +1 412 246 5810. E-mail address: [email protected] (A. Zuckoff). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2005.12.001
grief and substance abuse outcomes were assessed has yet been reported. A number of terms have been used in the literature to designate grief that is persistent and impairing. However, until the past decade, this work was not empirically based and there was no reliable way to identify such a condition. In contrast, several research groups have now identified a grief-specific condition characterized by prominent separation distress and causing chronic and clinically significant impairment (Horowitz, Siegel, Holen, & Bonanno, 1997; Prigerson et al., 1999). Sufferers display persistent yearning or longing for the deceased, loneliness, preoccupation with thoughts of the deceased, intrusive images or memories, avoidance behaviors, anger and bitterness, survivor guilt, and inability to accept the death. This postloss stress syndrome is called complicated grief. A self-report instrument, the Inventory of Complicated Grief (ICG; Prigerson, Maciejewski, et al., 1995), was developed to assess grief-specific symptoms; a score of k25 identifies the syndrome when the instrument is administered
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z6 months after a death. Factor analysis showed the ICG to measure a single underlying construct. The measure demonstrated excellent internal consistency (a = .94) and high 6-month retest reliability (r = .80). It showed good convergence (all r = .70–.87) with other measures designed to assess grief-related distress while also differentiating complicated grievers from normal grievers based on negative health consequences of bereavement. Several investigators have replicated the finding that complicated grief symptoms can be distinguished from depression and anxiety symptomatology (Boelen & van den Bout, 2005; Boelen, van den Bout, & de Keisjer, 2003; Ogrodniczuk et al., 2003; Prigerson et al., 1996; Prigerson, Frank, et al., 1995). Complicated grief is a postloss stress syndrome that bears some resemblance to posttraumatic stress disorder (PTSD). However, traumatic stress results from exposure to a life-threatening event, whereas complicated grief results from the loss of a life-sustaining person. As a result, sadness and loneliness are prominent in complicated grief, whereas fear and arousal are more pronounced in PTSD. Furthermore, symptoms of longing and yearning, as well as pleasurable reveries, are characteristic of complicated grief and clearly distinct from traumatic stress symptoms. Studies have shown moderate rates of comorbidity among complicated grief, major depressive disorder (MDD), and PTSD—similar to rates of comorbidity for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) mood and anxiety disorders (Melhem et al., 2001, 2004; Silverman et al., 2000). In studies that controlled for the presence of both MDD and PTSD, complicated grief was associated with greater mental health and psychosocial impairments (Ott, 2003; Prigerson et al., 1997, 2000; Silverman et al., 2000), higher risk of suicidality (Latham & Prigerson, 2004), and physical health problems in the aftermath of a loss (Chen et al., 1999). A summary of the evidence for the specificity of complicated grief can be found in the work of Lichtenthal, Cruess, and Prigerson (2004). Emergent evidence suggests a link between intense grief and worsening of substance use (Prigerson et al., 1997). Parents who lost a child were found to be at significantly higher risk for hospitalization for substance abuse than parents who had not lost a child (Li, Laurson, Precht, Olsen, & Mortensen, 2005); the effect was especially strong on bereaved mothers, whose relative risk of hospitalization was more than double that of mothers who were not bereaved. In a survey study (Shear, Zuckoff, et al., 2005), we found a high rate of complicated grief among patients in a methadone maintenance program. Psychiatric severity, generally (Kranzler, Del Boca, & Rounsaville, 1996; McLellan, Luborsky, Woody, O’Brien, & Druley, 1983), and co-occurring mood or anxiety disorder, specifically (Charney, Paraherokis, Negrete, & Gill, 1998; Dodge, Sindelar, & Sinha, 2005; Hasin et al.,
2002; Ouimette, Brown, & Najavits, 1998), are associated with poor SUD treatment outcomes. Treatment of co-occurring PTSD has been shown to be a positive predictor of 5-year substance use remission rates (Ouimette, Moos, & Finney, 2003), and successful treatment of depression diminishes the quantity of substance use (Nunes & Levin, 2004). Persons with SUDs who have co-occurring complicated grief would likewise seem likely to benefit from effective treatment of the syndrome. We developed and pilot tested (Shear, Frank, et al., 2001) a novel complicated grief treatment (CGT). Results of a randomized controlled trial of 16 sessions of CGT showed this treatment to be superior to a 16-session standard psychotherapy control (Shear, Frank, Houck, & Reynolds, 2005). However, persons with SUDs have been excluded from these studies, in the belief that special adaptations would be required to make treating them safe and feasible. We therefore undertook a treatment development project to adapt CGT for persons who abuse or are dependent on substances. The results of an open prospective pilot study are reported here.
2. Materials and methods 2.1. Participants Sixteen adults (nine women and seven men) who were ineligible for our randomized controlled trial due to a co-occurring SUD participated in this study. Eligible participants were z6 months postloss, scored z30 on the ICG (the higher cutoff was used to ensure caseness), and met DSM-IV (APA, 1994) criteria for substance dependence or abuse during the past 6 months. Exclusion criteria included psychosis, mania, uncontrolled medical illness, and active suicidality requiring hospitalization. The study was approved by the University of Pittsburgh Institutional Review Board, and written informed consent was obtained from all participants before study procedures were initiated. 2.2. Measures Participants were assessed by independent evaluators. Diagnoses of Axis I disorders were made at baseline with the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996). The ICG was given at baseline, weekly during treatment, and posttreatment to assess grief symptoms. The Beck Depression Inventory (BDI; Beck, 1978) was given at treatment sessions to measure symptoms of depression. The Timeline Followback (TLFB; Sobell & Sobell, 1996), a semistructured interview with very good psychometric properties for quantifying both alcohol and drug use (Fals-Stewart, O’Farrell, Freitas, McFarlin, & Rutigliano, 2000), was conducted at baseline to establish lifetime and 90-day substance use frequency and at treatment sessions to record in-treatment days of
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use. Cravings were assessed at each treatment session via three self-report Likert-scale questions rated 0 – 4, querying how often, how intensely, and how long participants wanted to use a substance during the previous week. A breathalyzer test for alcohol was given before each treatment session. 2.3. Procedure 2.3.1. Treatment All participants were offered 24 individual sessions of manual-guided treatment for complicated grief and substance use treatment (CGSUT), delivered over approximately 6 months. All treatments were conducted by the first author (who has a PhD in clinical psychology and has more than 10 years of experience in the treatment of patients with co-occurring disorders) in our university-based clinic and in a community clinic attended primarily by low-income African-American patients. Persons with SUDs who suffer from co-occurring emotionally activating conditions are especially challenged in maintaining stable abstinence from substances. Our goal in adapting CGT for this population was to help patients achieve sufficient initial improvement in substance use behavior so that they could learn skills for managing intense emotions and safely engage in targeted strategies for reducing grief symptomatology. Long-term relief of grief-related emotional activation, in turn, was expected to increase the likelihood that patients sustain improvement in their SUDs. CGSUT thus combines components targeting achievement of abstinence from substances and enhanced tolerance for emotional activation without relapse (motivational interviewing [MI] and emotion coping and communication skills), with a proven approach to treatment of complicated grief (Shear, Frank, et al., 2005). MI (Miller & Rollnick, 2002), designed to elicit and strengthen commitment to change substance use behavior, was selected for its efficacy as a brief intervention for SUDs (Burke, Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, 2005). Three MI sessions incorporate techniques that include a decisional balance discussion, a values card sort exercise, and a written change plan. Five sessions of skills building for emotion coping and communication draw on the approaches of emotion-focused therapy (Greenberg & Paivio, 1997) and relationship enhancement (Accordino & Guerney, 2001). Specific strategies for enhancing recognition and management of difficult emotions include diaphragmatic breathing, safe-place mental imagery, and feelings recording exercises. Strategies for improving communication include skills for listening to and understanding others and for effectively expressing feelings, perceptions, and wishes to others. As in its standard form, CGT is conducted over 16 sessions, including the introductory, active grief treatment, and termination phases. A detailed description of CGT can be found in the work of Harkness, Shear, Frank, and Silberman (2002), Shear, Frank, et al. (2001), Shear, Frank,
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et al. (2005), Shear, Zuckoff, and Frank (2001), and Shear, Zuckoff, Melhem, and Gorscak (in press). Briefly, the treatment conceptualizes complicated grief as a problem in coping with an important loss, resulting in specific symptoms. As this condition bears some resemblance to both MDD and PTSD, the treatment integrates techniques from interpersonal therapy for depression (Weissman, Markowitz, & Klerman, 2000) and cognitive–behavioral therapy for PTSD (Foa & Rothbaum, 1998) into a framework guided by Stroebe and Schut’s (1999) dual-process model of coping with bereavement, which posits that adaptive coping requires attending to both loss-oriented and restoration-oriented tasks. Among the techniques used in this treatment is imaginal revisiting. Similar to prolonged exposure in PTSD treatment, this exercise is highly emotionally evocative. The use of exposure techniques has repeatedly been found to be efficacious, yet their use with persons with SUDs has been questioned due to concerns about low tolerance for negative affects (Pitman et al., 1991). Back, Dansky, Carroll, Foa, and Brady (2001) and Triffleman, Carroll, and Kellogg (1999) described procedures for safely using exposure strategies in this population, which we adopted in a modified form. Brady, Dansky, Back, Foa, and Carroll (2001) conducted an open pilot study on an outpatient treatment for PTSD and cocaine dependence, which included use of in vivo and imaginal exposure to reduce PTSD symptom severity, and found large effect sizes for both substance use and PTSD outcomes. To maximize safety, we initiated the emotionally evocative revisiting exercise only with patients who showed no increase in substance use or cravings and no suicidal ideation after telling the therapist the story of the death. Our revisiting procedure utilized incremental and modulated imaginal engagement with this story, with provisions for flexibility and clinical judgment regarding decisions to start and continue the exposure process. Self-reported substance use and cravings were monitored at each treatment session and addressed as needed. Breathalyzer tests were administered at each treatment session. Any clinically significant deterioration in substance use behavior led to suspension of evocative techniques and refocusing on substance use goals. 2.3.2. Statistical analyses Comparisons were made to identify differences among treatment completers and noncompleters using Mann– Whitney U two-sided exact tests for continuous data and Fisher exact tests for categorical data. Pretreatment and posttreatment comparisons were made for completers and for the entire sample on complicated grief, substance use, and depression outcome variables using Wilcoxon signed rank tests. A mixed model was fitted on average cravings over time, with participants’ intercept and slope as random effects. Effect sizes were calculated using Cohen’s d for differences and Cohen’s h for proportions. a was set at .05.
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3. Results 3.1. Preliminary analyses 3.1.1. Participant characteristics Nine women and seven men signed informed consent forms for the study and had at least one treatment session. The mean time since the death that was the focus of treatment was 9.8 years (SD = 9.7 years, range = 0.7–31.7 years, Mdn = 7.6 years). Seven participants were grieving over violent deaths, and nine participants were grieving over nonviolent deaths. The mean age of the participants was 42.3 years (SD = 9.8 years, range = 24 –57 years). Eight participants were African American, seven were Caucasian, and one was Native American. One was married; six were never married; and nine were widowed, separated, or divorced. Four had lower than high school education, two were high school graduates or equivalent, six had some postsecondary education, and four had a postsecondary degree. Most (n = 12) were unemployed. SUDs at baseline included alcohol dependence (n = 3) or abuse (n = 4), cannabis dependence (n = 3) or abuse (n = 1), and cocaine dependence (n = 3). Three participants entered treatment with opiate dependence and were on agonist therapy (methadone). Participants reported use of any substance in their lifetime a median of 24 years (1,250 weeks, range = 484–2,056 weeks). In their lifetime, all 16 participants used alcohol (Mdn = 546 weeks, range = 130– 2,056 weeks), 15 used cannabis (Mdn = 260 weeks, range = 0 –1,430 weeks), 12 used cocaine (Mdn = 172 weeks, range = 0–1,496 weeks), 11 used hallucinogens (Mdn = 1 week, range = 0–156 weeks), 9 used amphetamines (Mdn = 1 week, range = 0 –364 weeks), 9 used opiates (Mdn = 1 week, range = 0 –1,673 weeks), 7 used benzodiazepines (Mdn = 1 week, range = 0–520 weeks), 5 used inhalants (Mdn = 0 week, range = 0 –6 weeks), and 4 used hypnotics (Mdn = 0 week, range = 0–520 weeks). Excluding prescribed methadone, during the 90 days prior to baseline, participants used a mean of 1.6 (range = 0 –3) types of substances and used substances on 58% (SD = 36.5) of days. During this period, one participant on methadone was otherwise abstinent; 12 participants drank alcohol (median drinks per drinking day = 3, range = 0 –17), 9 used cannabis, 4 used cocaine, 1 used benzodiazepines, and 1 used opiates. All participants had at least one nonsubstance use DSMIV Axis I diagnosis at baseline (M = 2.1, range = 1–5), including MDD (n = 12), PTSD (n = 11), panic disorder (n = 4), generalized anxiety disorder (n = 4), and specific phobia (n = 1). Eleven participants were on psychotropic medication during study participation: 10 on antidepressants, 3 on benzodiazepines, 3 on neuroleptics, 2 on mood stabilizers, and 1 on nonbenzodiazepine sleep medication. In addition to the three participants on methadone who were enrolled in public methadone maintenance programs, two participants recruited from our low-income community
clinic continued to receive supportive counseling during study participation and one participant was enrolled in a residential program for mothers with addictions. All participants judged grief to be their primary problem, with the exception of their SUDs. 3.1.2. Comparison of treatment completers and noncompleters Eight participants (five men and three women) completed the treatment, whereas six women and two men were noncompleters. The mean number of sessions for noncompleters was 9.3 (SD = 5.5, range = 1–15). One participant dropped out because of unwillingness to continue grief-focused procedures, and three dropped out for unknown reasons. Two participants were withdrawn for medical reasons (abnormal electrocardiogram, gastrointestinal disorder), and one was withdrawn for failure to attend treatment sessions. One participant was withdrawn for worsening substance use and depression after nine sessions. This participant was one of two enrolled early in the study whose condition worsened after telling the story of the death during the first treatment session. The other participant was able to restabilize and successfully complete the treatment. Nonetheless, after these events, we changed the protocol such that the story was not told until after the patient completed the initial treatment phase; no further case of worsening occurred. Two completers each had one positive breathalyzer test; no noncompleter had positive breathalyzers. The two sessions in question were rescheduled, and we ensured that the patient was seen home safely, with no further complication. Although higher proportions of women and those grieving over violent deaths were noncompleters, there was no statistically significant relationship between completion and sex (71% males vs. 37% females; h = .78, p = .31) or type of death (67% nonviolent vs. 29% violent; h = .78, p = .31). Among participants on antidepressants, six completed treatment and four did not, whereas two participants not on antidepressants completed treatment and four did not ( p = .61). Although the difference was not significant, completers had a lower proportion of abstinent days at baseline (32% vs. 53%; p = .51). 3.2. Treatment outcomes 3.2.1. Symptom scores Grief, depression, and substance use symptom outcomes are summarized in Table 1. Significant pretreatment-to-posttreatment reductions were found in ICG scores in completers (M = 30.9, SD = 15.4, S = 18, p = .01) and intent-to-treat analysis (M = 15.3, SD = 19.7, S = 48, p = .01), with effect sizes of 2.01 and 0.78, respectively. In a comparable CGT pilot study (Shear, Frank, et al., 2001), mean reductions in ICG scores were 22.8 (SD = 13.14, z = 3.11, p = .002) among
A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211
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Table 1 Scores on measures of grief, depression, and substance use in CGSUT a participants ICG Participant group
Pretreatment
Completer (n = 8) M 49.0 SD 9.8 Noncompleter (n = 8)b M 46.1 SD 9.7 Intent-to-treat (n = 16) M 47.6 SD 9.5
BDI Posttreatment
D
TLFB percent days abstinent
Initial session
Final session
D
Pretreatment
In treatment
D
18.1 14.0
30.94 15.4
26.5 12.7
11.0 10.9
15.54 5.5
32.0 26.8
58.5 33.7
26.544 29.8
46.4 8.2
0.3 6.5
27.0 10.1
26.6 13.8
0.4 7.3
52.6 43.5
67.0 31.0
14.4 55.4
32.3 18.3
15.34 19.7
26.8 11.1
18.8 14.5
7.94 10.0
42.3 36.5
62.8 31.6
20.444 43.4
a
Manual-guided individual outpatient treatment conducted in 24 sessions over approximately 6 months. Last observation carried forward. 4 p = .01. 44 p b .05.
b
completers and 16.9 (SD = 19.99, z = 3.51, p b .001) in intent-to-treat analysis, with effect sizes of 2.19 and 1.45, respectively. BDI scores showed corresponding reductions for both completer (M = 15.5, SD = 5.5, S = 18, p = .01) and intentto-treat (M = 7.9, SD = 10.0, S = 40, p = .01) groups, with effect sizes of 2.82 and 0.79, respectively. Again, this was similar to reductions in BDI scores in the CGT pilot study for the completer (M = 13.1, SD = 10.19, z = 2.98, p = .003) and intent-to-treat (M = 10.4, SD = 9.93, z = 3.44, p = .001) groups, with effect sizes of 1.80 and 1.16, respectively. TLFB percent days abstinent from all substances increased significantly among the completer (M = 26.5, SD = 29.8, S = 15, p = .04) and the intent-to-treat (M = 20.4, SD = 43.4, S = 39, p = .04) groups. Effect sizes were 0.89 and 0.47, respectively. Among completers, mean reduction in ICG score was 30.8 for patients on antidepressants (n = 6) and 31.0 for patients not on antidepressants (n = 2). In intent-to-treat analysis, mean reduction in ICG score was 19.1 (SD =20.3) for the 10 participants on antidepressants and 9.0 (SD = 18.7) for the 6 participants not on antidepressants ( p = .31). 3.2.2. Cravings A significant negative slope was found in the mixedmodel analysis of the intent-to-treat sample, such that average cravings decreased over time. Mean craving score was 2.2 at treatment initiation, whereas the predicted value at treatment completion was 1.6, F (1, 13) = 5.30, p = .04, d = 1.30.
4. Discussion Complicated grief is a chronic and debilitating condition. The identification of this postloss syndrome led to the development of a targeted efficacious treatment, but the treatment was previously unavailable to those with SUDs, despite the long-recognized prominence of grief problems among
them. Our pilot study represents the first effort at establishing the feasibility of delivering CGT in this population. This study is limited by its small number of participants and its open treatment design. In addition, the first author, who was the primary developer of the adapted treatment, administered all treatments. For these reasons, the effect sizes we observed are likely to overestimate those we would see in a larger randomized trial that controls for effects of time and attention, as well as therapist effects. Nevertheless, the results, although preliminary, are promising and suggest that a grief-focused treatment, combined with MI and skills building for emotion coping and communication, can feasibly be delivered to patients with extensive substance use histories who are actively using substances upon treatment entry. The large effect sizes for changes in griefrelated symptoms and the concomitant improvement in substance use and cravings support the idea that this treatment is of potential benefit. Clearly, it is important to be cautious when using a treatment that is emotionally evocative in persons with SUDs. We took several steps to address this concern. We added a five-session coping skills component to our adapted treatment, began revisiting exercises only with patients judged ready for them, and monitored cravings at each session. We were flexible in our use of evocative procedures, allowing patients to proceed at a pace they found manageable. When we discovered, in two early cases, that telling the story of the death in the first session was followed by worsening of substance use, we changed our procedure such that their story was not told until after coping skills had been taught; we saw no further case of deterioration. Only 50% of the participants completed the treatment. Although this rate was lower than that desirable, it is similar to that found in our pilot study on CGT that excluded persons with SUDs. Other SUD treatment trials have recorded high rates of dropout (e.g., completers = 28%; Crits-Cristoph et al., 1999). In their open pilot study of an exposure-based treatment for PTSD and cocaine dependence,
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Brady et al. (2001) reported a completion rate of 39%. Nonetheless, efforts to increase treatment retention in CGSUT should be an important part of future development work. Our sample was heterogeneous where choice of substance and pretreatment severity of substance use were concerned, and we assessed substance use outcomes solely through the TLFB interview and weekly cravings ratings. Concomitant psychotropic medication use was also heterogeneous, and several participants received psychosocial care outside the study. Future studies would benefit from drawing a sample from a more homogeneous population, using a range of measures of substance use severity and outcome (including biologic measures; i.e., urinalysis and breathalyzer testing), and controlling for the use of antidepressant medication and external psychosocial treatment. Follow-up assessments are also needed to determine whether gains in complicated grief symptoms are durable and whether decreases in substance use, such as those found in our sample, continue following treatment, especially among those people who attained a large reduction in complicated grief symptoms. In summary, these findings provide support for further research utilizing our adaptation of CGT for persons with SUDs. Development and dissemination of an efficacious treatment for complicated grief in persons with SUDs would have the potential to alleviate suffering and improve substance use treatment outcomes in those who suffer from this condition.
Acknowledgments This work was supported by grants from the National Institute of Mental Health (R01 MH60783 and P30 MH30915) and the National Institute on Drug Abuse (Administrative Supplement MH60783). We are grateful to Krissa Caroff, B.A., Jacqueline Fury, B.A., and Randi Taylor, Ph.D., for their assistance in the conduct of this study.
References Accordino, M. P., & Guerney, B. G., Jr. (2001). The empirical validation of Relationship Enhancement Couple and Family Therapy. In D. J. Cain, & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 403 – 442). Washington, DC7 American Psychological Association. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC7 APA. Back, S. E., Dansky, B. S., Carroll, K. M., Foa, E. B., & Brady, K. T. (2001). Exposure therapy in the treatment of PTSD among cocaine dependent patients: Description of procedures. Journal of Substance Abuse Treatment, 21, 35 – 45. Beck, A. T. (1978). Depression inventory. Philadelphia7 Center for Cognitive Therapy.
Bellwood, L. R. (1975). Grief work in alcoholism treatment. Alcohol Health and Research World, Exp Issue, 8 – 11. Blankfield, A. (1982/1983). Grief and alcohol. American Journal of Drug and Alcohol Abuse, 9, 435 – 446. Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: A confirmatory factor analysis study. American Journal of Psychiatry, 162, 2175 – 2177. Boelen, P. A., van den Bout, J., & de Keisjer, J. (2003). Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: A replication study with bereaved mental health care patients. American Journal of Psychiatry, 160, 1339 – 1341. Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in the treatment of PTSD among cocainedependent individuals: Preliminary findings. Journal of Substance Abuse Treatment, 21, 47 – 54. Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843 – 861. Charney, D., Paraherokis, A., Negrete, J., & Gill, K. (1998). The impact of depression on the outcome of addictions treatment. Journal of Substance Abuse Treatment, 15, 123 – 130. Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavementrelated psychological distress in health outcomes. Psychological Medicine, 29, 367 – 380. Crits-Cristoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L. S., et al. (1999). Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56, 493 – 502. Dodge, R., Sindelar, J., & Sinha, R. (2005). The role of depression symptoms in predicting drug abstinence in outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 28, 189 – 196. Fals-Stewart, W., O’Farrell, T. J., Freitas, T. T., McFarlin, S. K., & Rutigliano, P. (2000). The Timeline Followback reports of psychoactive substance use by drug-abusing patients: Psychometric properties. Journal of Consulting and Clinical Psychology, 68, 134 – 144. First, M. B., Spitzer, L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM IV Axis I disorders. New York7 New York State Psychiatric Institute. Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive–behavioral therapy for PTSD. New York7 Guilford. Greenberg, L., & Paivio, S. (1997). Working with emotions in psychotherapy. New York7 Guilford. Harkness, K. L., Shear, M. K., Frank, E., & Silberman, R. A. (2002). Traumatic grief treatment: Case histories of 4 patients. Journal of Clinical Psychiatry, 63, 1113 – 1120. Hasin, D., Liu, X., Nunes, E., McCloud, S., Samet, S., & Endicott, J. (2002). Effects of major depression on remission and relapse of substance dependence. Archives of General Psychiatry, 59, 375 – 380. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91 – 111. Horowitz, M. J., Siegel, B., Holen, A., & Bonanno, G. A. (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154, 904 – 910. Kranzler, H. R., Del Boca, F. K., & Rounsaville, B. J. (1996). Co-morbid psychiatric diagnosis predicts three-year outcomes in alcoholics: A posttreatment natural history study. Journal of Studies on Alcohol, 57, 619 – 626. Latham, A. E., & Prigerson, H. G. (2004). Suicidality and bereavement: Complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide & Life-Threatening Behavior, 34, 350 – 362. Li, J., Laurson, T. M., Precht, D. H., Olsen, J., & Mortensen, P. B. (2005). Hospitalization for mental illness among parents after the death of a child. New England Journal of Medicine, 352, 1190 – 1196. 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, 637 – 662.
A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211 McLellan, A. T., Luborsky, L., Woody, G. E., O’Brien, C. P., & Druley, K. A. (1983). Predicting response to alcohol and drug abuse treatments: Role of psychiatric severity. Archives of General Psychiatry, 40, 620 – 625. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., III, & Brent, D. (2004). Traumatic grief among adolescents exposed to a peer’s suicide. American Journal of Psychiatry, 161, 1411 – 1416. Melhem, N. M., Rosales, C., Karageorge, J., Reynolds, C. F., III, Frank, E., & Shear, M. K. (2001). Comorbidity of Axis I disorders in patients with traumatic grief. Journal of Clinical Psychiatry, 62, 884 – 887. Miller, W. R., & Rollnick, R. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York7 Guilford. Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. Journal of the American Medical Association, 291, 1887 – 1896. Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., Weideman, R., McCallum, M., Azim, H. F., et al. (2003). Differentiating symptoms of complicated grief and depression among psychiatric outpatients. Canadian Journal of Psychiatry, 48, 87 – 93. Ott, C. H. (2003). The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27, 249 – 272. Ouimette, P., Moos, R. H., & Finney, J. W. (2003). PTSD treatment and 5year remission among patients with substance use and posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 71, 410 – 414. Ouimette, P. C., Brown, P. J., & Najavits, L. M. (1998). Course and treatment of patients with both substance use and posttraumatic stress disorder. Addictive Behaviors, 23, 785 – 795. Pitman, R. K., Altman, B., Greenwald, E., Longpre, R. E., Macklin, M. L., Poire, R. E., et al. (1991). Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry, 52, 17 – 20. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., III, Shear, M. K., Day, N., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616 – 623. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., III, Shear, M. K., Newsom, J. T., et al. (1996). Complicated grief as a disorder distinct from bereavement-related depression and anxiety: A replication study. American Journal of Psychiatry, 153, 1484 – 1486. Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., III, Anderson, B., Houck, G. S., et al. (1995). Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22 – 30.
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Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F., III, Bierhals, A. J., Newsom, J. T., Fasiczka, A., et al. (1995). Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65 – 79. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Kasl, S. V., Maciejewski, P. K., Silverman, G. K., et al. (2000). Grief and its relation to posttraumatic stress disorder. In D. Nutt, & J. R. T. Davidson (Eds.), Post traumatic stress disorders: Diagnosis, management, and treatment (pp. 163 – 186). New York7 Martin Dunitz. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F., Maciejewski, P. K., Davidson, J. R. T., et al. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, 67 – 73. Shear, M. K., Frank, E., Foa, E., Cherry, C., Reynolds, C. F., III, Vander Bilt, J., et al. (2001). Traumatic grief treatment: A pilot study. American Journal of Psychiatry, 158, 1506 – 1508. Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. Journal of the American Medical Association, 293, 2601 – 2608. Shear, M. K., Zuckoff, A., & Frank, E. (2001). The syndrome of traumatic grief. CNS Spectrums, 6, 339 – 346. Shear, K., Zuckoff, A., Frank, E., Daley, D. C., Cornelius, J., Houck, P., et al. (2005). Complicated grief and substance use in methadone maintenance patients: A survey study. Poster presented at the 67th annual scientific meeting of the College on Problems of Drug Dependence, Orlando, FL. Shear, M. K., Zuckoff, A., Melhem, N., & Gorscak, B. J. (in press). The syndrome of traumatic grief and its treatment. In L. A. Schein, H. I. Spitz, G. M. Burlingame, & P. R. Muskin (Eds.), Psychological effects of catastrophic disasters: Group approaches to treatment. New York7 Haworth Press. Silverman, G. K., Jacobs, S. C., Kasl, S. V., Shear, M. K., Maciejewski, P. K., Noaghiul, F. S., et al. (2000). Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychological Medicine, 30, 857 – 862. Sobell, L. C., & Sobell, M. B. (1996). Timeline Followback user’s guide: A calendar method for assessing alcohol and drug use. Toronto, Ontario, Canada7 Addiction Research Foundation. Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197 – 224. Triffleman, E., Carroll, K., & Kellogg, S. (1999). Substance dependence posttraumatic stress disorder therapy: An integrated cognitive–behavioral approach. Journal of Substance Abuse Treatment, 17, 3 – 14. Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York7 Basic Books.
Treating complicated grief and substance use disorders: A pilot study Allan Zuckoff, (Ph.D.)4, Katherine Shear, (M.D.), Ellen Frank, (Ph.D.), Dennis C. Daley, (Ph.D.), Karen Seligman, (M.Ed.), Russell Silowash, (B.A.) Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213-2393, USA Received 13 May 2005; received in revised form 15 November 2005; accepted 8 December 2005
Abstract Empirically supported treatments for co-occurring substance use disorders (SUDs) and grief problems are lacking, despite the salience of grief pathology in substance abusers. Identification of a syndrome of complicated grief, distinct from bereavement-related depression and anxiety, led to the development of a targeted treatment, but this treatment has not been tried with persons with SUDs. We recruited 16 adults with complicated grief and substance dependence or abuse into an open pilot study of a manualized 24-session treatment, incorporating motivational interviewing and emotion coping and communication skills into our efficacious complicated grief treatment. Completer and intent-to-treat analyses showed significant reductions in Inventory of Complicated Grief and Beck Depression Inventory scores, with large effect sizes. Timeline Followback percent days abstinent increased significantly in both analyses, with medium to large effect sizes, and cravings declined significantly. Study limitations notwithstanding, complicated grief and substance use treatment appears to be a promising intervention that merits further research. D 2006 Elsevier Inc. All rights reserved. Keywords: Complicated grief; Substance abuse; Motivational interviewing; Exposure therapy; Emotion coping
1. Introduction Grief has long been recognized as salient in treating persons with substance use disorders (SUDs). Bellwood (1975) described addressing bunresolved grief Q as a key to successful alcoholism treatment, and Blankfield (1982/1983) found intense grief or significant bereavement in 20% of consecutive inpatient admissions to a substance abuse treatment center. Yet, despite numerous published clinical accounts of grief treatment in those who abuse or are dependent on substances, no controlled study in which grief-specific symptoms were defined or in which both
Portions of this work were presented at the 158th Annual Meeting of the American Psychiatric Association, Atlanta, GA, May 26, 2005; at the 67th Annual Scientific Meeting of the College on Problems of Drug Dependence, Orlando, FL, June 21, 2005; and at the 11th International Conference on Treatment of Addictive Behavior, Santa Fe, NM, February 1, 2006. 4 Corresponding author. Tel.: +1 412 246 5817; fax: +1 412 246 5810. E-mail address: [email protected] (A. Zuckoff). 0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2005.12.001
grief and substance abuse outcomes were assessed has yet been reported. A number of terms have been used in the literature to designate grief that is persistent and impairing. However, until the past decade, this work was not empirically based and there was no reliable way to identify such a condition. In contrast, several research groups have now identified a grief-specific condition characterized by prominent separation distress and causing chronic and clinically significant impairment (Horowitz, Siegel, Holen, & Bonanno, 1997; Prigerson et al., 1999). Sufferers display persistent yearning or longing for the deceased, loneliness, preoccupation with thoughts of the deceased, intrusive images or memories, avoidance behaviors, anger and bitterness, survivor guilt, and inability to accept the death. This postloss stress syndrome is called complicated grief. A self-report instrument, the Inventory of Complicated Grief (ICG; Prigerson, Maciejewski, et al., 1995), was developed to assess grief-specific symptoms; a score of k25 identifies the syndrome when the instrument is administered
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z6 months after a death. Factor analysis showed the ICG to measure a single underlying construct. The measure demonstrated excellent internal consistency (a = .94) and high 6-month retest reliability (r = .80). It showed good convergence (all r = .70–.87) with other measures designed to assess grief-related distress while also differentiating complicated grievers from normal grievers based on negative health consequences of bereavement. Several investigators have replicated the finding that complicated grief symptoms can be distinguished from depression and anxiety symptomatology (Boelen & van den Bout, 2005; Boelen, van den Bout, & de Keisjer, 2003; Ogrodniczuk et al., 2003; Prigerson et al., 1996; Prigerson, Frank, et al., 1995). Complicated grief is a postloss stress syndrome that bears some resemblance to posttraumatic stress disorder (PTSD). However, traumatic stress results from exposure to a life-threatening event, whereas complicated grief results from the loss of a life-sustaining person. As a result, sadness and loneliness are prominent in complicated grief, whereas fear and arousal are more pronounced in PTSD. Furthermore, symptoms of longing and yearning, as well as pleasurable reveries, are characteristic of complicated grief and clearly distinct from traumatic stress symptoms. Studies have shown moderate rates of comorbidity among complicated grief, major depressive disorder (MDD), and PTSD—similar to rates of comorbidity for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA], 1994) mood and anxiety disorders (Melhem et al., 2001, 2004; Silverman et al., 2000). In studies that controlled for the presence of both MDD and PTSD, complicated grief was associated with greater mental health and psychosocial impairments (Ott, 2003; Prigerson et al., 1997, 2000; Silverman et al., 2000), higher risk of suicidality (Latham & Prigerson, 2004), and physical health problems in the aftermath of a loss (Chen et al., 1999). A summary of the evidence for the specificity of complicated grief can be found in the work of Lichtenthal, Cruess, and Prigerson (2004). Emergent evidence suggests a link between intense grief and worsening of substance use (Prigerson et al., 1997). Parents who lost a child were found to be at significantly higher risk for hospitalization for substance abuse than parents who had not lost a child (Li, Laurson, Precht, Olsen, & Mortensen, 2005); the effect was especially strong on bereaved mothers, whose relative risk of hospitalization was more than double that of mothers who were not bereaved. In a survey study (Shear, Zuckoff, et al., 2005), we found a high rate of complicated grief among patients in a methadone maintenance program. Psychiatric severity, generally (Kranzler, Del Boca, & Rounsaville, 1996; McLellan, Luborsky, Woody, O’Brien, & Druley, 1983), and co-occurring mood or anxiety disorder, specifically (Charney, Paraherokis, Negrete, & Gill, 1998; Dodge, Sindelar, & Sinha, 2005; Hasin et al.,
2002; Ouimette, Brown, & Najavits, 1998), are associated with poor SUD treatment outcomes. Treatment of co-occurring PTSD has been shown to be a positive predictor of 5-year substance use remission rates (Ouimette, Moos, & Finney, 2003), and successful treatment of depression diminishes the quantity of substance use (Nunes & Levin, 2004). Persons with SUDs who have co-occurring complicated grief would likewise seem likely to benefit from effective treatment of the syndrome. We developed and pilot tested (Shear, Frank, et al., 2001) a novel complicated grief treatment (CGT). Results of a randomized controlled trial of 16 sessions of CGT showed this treatment to be superior to a 16-session standard psychotherapy control (Shear, Frank, Houck, & Reynolds, 2005). However, persons with SUDs have been excluded from these studies, in the belief that special adaptations would be required to make treating them safe and feasible. We therefore undertook a treatment development project to adapt CGT for persons who abuse or are dependent on substances. The results of an open prospective pilot study are reported here.
2. Materials and methods 2.1. Participants Sixteen adults (nine women and seven men) who were ineligible for our randomized controlled trial due to a co-occurring SUD participated in this study. Eligible participants were z6 months postloss, scored z30 on the ICG (the higher cutoff was used to ensure caseness), and met DSM-IV (APA, 1994) criteria for substance dependence or abuse during the past 6 months. Exclusion criteria included psychosis, mania, uncontrolled medical illness, and active suicidality requiring hospitalization. The study was approved by the University of Pittsburgh Institutional Review Board, and written informed consent was obtained from all participants before study procedures were initiated. 2.2. Measures Participants were assessed by independent evaluators. Diagnoses of Axis I disorders were made at baseline with the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996). The ICG was given at baseline, weekly during treatment, and posttreatment to assess grief symptoms. The Beck Depression Inventory (BDI; Beck, 1978) was given at treatment sessions to measure symptoms of depression. The Timeline Followback (TLFB; Sobell & Sobell, 1996), a semistructured interview with very good psychometric properties for quantifying both alcohol and drug use (Fals-Stewart, O’Farrell, Freitas, McFarlin, & Rutigliano, 2000), was conducted at baseline to establish lifetime and 90-day substance use frequency and at treatment sessions to record in-treatment days of
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use. Cravings were assessed at each treatment session via three self-report Likert-scale questions rated 0 – 4, querying how often, how intensely, and how long participants wanted to use a substance during the previous week. A breathalyzer test for alcohol was given before each treatment session. 2.3. Procedure 2.3.1. Treatment All participants were offered 24 individual sessions of manual-guided treatment for complicated grief and substance use treatment (CGSUT), delivered over approximately 6 months. All treatments were conducted by the first author (who has a PhD in clinical psychology and has more than 10 years of experience in the treatment of patients with co-occurring disorders) in our university-based clinic and in a community clinic attended primarily by low-income African-American patients. Persons with SUDs who suffer from co-occurring emotionally activating conditions are especially challenged in maintaining stable abstinence from substances. Our goal in adapting CGT for this population was to help patients achieve sufficient initial improvement in substance use behavior so that they could learn skills for managing intense emotions and safely engage in targeted strategies for reducing grief symptomatology. Long-term relief of grief-related emotional activation, in turn, was expected to increase the likelihood that patients sustain improvement in their SUDs. CGSUT thus combines components targeting achievement of abstinence from substances and enhanced tolerance for emotional activation without relapse (motivational interviewing [MI] and emotion coping and communication skills), with a proven approach to treatment of complicated grief (Shear, Frank, et al., 2005). MI (Miller & Rollnick, 2002), designed to elicit and strengthen commitment to change substance use behavior, was selected for its efficacy as a brief intervention for SUDs (Burke, Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, 2005). Three MI sessions incorporate techniques that include a decisional balance discussion, a values card sort exercise, and a written change plan. Five sessions of skills building for emotion coping and communication draw on the approaches of emotion-focused therapy (Greenberg & Paivio, 1997) and relationship enhancement (Accordino & Guerney, 2001). Specific strategies for enhancing recognition and management of difficult emotions include diaphragmatic breathing, safe-place mental imagery, and feelings recording exercises. Strategies for improving communication include skills for listening to and understanding others and for effectively expressing feelings, perceptions, and wishes to others. As in its standard form, CGT is conducted over 16 sessions, including the introductory, active grief treatment, and termination phases. A detailed description of CGT can be found in the work of Harkness, Shear, Frank, and Silberman (2002), Shear, Frank, et al. (2001), Shear, Frank,
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et al. (2005), Shear, Zuckoff, and Frank (2001), and Shear, Zuckoff, Melhem, and Gorscak (in press). Briefly, the treatment conceptualizes complicated grief as a problem in coping with an important loss, resulting in specific symptoms. As this condition bears some resemblance to both MDD and PTSD, the treatment integrates techniques from interpersonal therapy for depression (Weissman, Markowitz, & Klerman, 2000) and cognitive–behavioral therapy for PTSD (Foa & Rothbaum, 1998) into a framework guided by Stroebe and Schut’s (1999) dual-process model of coping with bereavement, which posits that adaptive coping requires attending to both loss-oriented and restoration-oriented tasks. Among the techniques used in this treatment is imaginal revisiting. Similar to prolonged exposure in PTSD treatment, this exercise is highly emotionally evocative. The use of exposure techniques has repeatedly been found to be efficacious, yet their use with persons with SUDs has been questioned due to concerns about low tolerance for negative affects (Pitman et al., 1991). Back, Dansky, Carroll, Foa, and Brady (2001) and Triffleman, Carroll, and Kellogg (1999) described procedures for safely using exposure strategies in this population, which we adopted in a modified form. Brady, Dansky, Back, Foa, and Carroll (2001) conducted an open pilot study on an outpatient treatment for PTSD and cocaine dependence, which included use of in vivo and imaginal exposure to reduce PTSD symptom severity, and found large effect sizes for both substance use and PTSD outcomes. To maximize safety, we initiated the emotionally evocative revisiting exercise only with patients who showed no increase in substance use or cravings and no suicidal ideation after telling the therapist the story of the death. Our revisiting procedure utilized incremental and modulated imaginal engagement with this story, with provisions for flexibility and clinical judgment regarding decisions to start and continue the exposure process. Self-reported substance use and cravings were monitored at each treatment session and addressed as needed. Breathalyzer tests were administered at each treatment session. Any clinically significant deterioration in substance use behavior led to suspension of evocative techniques and refocusing on substance use goals. 2.3.2. Statistical analyses Comparisons were made to identify differences among treatment completers and noncompleters using Mann– Whitney U two-sided exact tests for continuous data and Fisher exact tests for categorical data. Pretreatment and posttreatment comparisons were made for completers and for the entire sample on complicated grief, substance use, and depression outcome variables using Wilcoxon signed rank tests. A mixed model was fitted on average cravings over time, with participants’ intercept and slope as random effects. Effect sizes were calculated using Cohen’s d for differences and Cohen’s h for proportions. a was set at .05.
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3. Results 3.1. Preliminary analyses 3.1.1. Participant characteristics Nine women and seven men signed informed consent forms for the study and had at least one treatment session. The mean time since the death that was the focus of treatment was 9.8 years (SD = 9.7 years, range = 0.7–31.7 years, Mdn = 7.6 years). Seven participants were grieving over violent deaths, and nine participants were grieving over nonviolent deaths. The mean age of the participants was 42.3 years (SD = 9.8 years, range = 24 –57 years). Eight participants were African American, seven were Caucasian, and one was Native American. One was married; six were never married; and nine were widowed, separated, or divorced. Four had lower than high school education, two were high school graduates or equivalent, six had some postsecondary education, and four had a postsecondary degree. Most (n = 12) were unemployed. SUDs at baseline included alcohol dependence (n = 3) or abuse (n = 4), cannabis dependence (n = 3) or abuse (n = 1), and cocaine dependence (n = 3). Three participants entered treatment with opiate dependence and were on agonist therapy (methadone). Participants reported use of any substance in their lifetime a median of 24 years (1,250 weeks, range = 484–2,056 weeks). In their lifetime, all 16 participants used alcohol (Mdn = 546 weeks, range = 130– 2,056 weeks), 15 used cannabis (Mdn = 260 weeks, range = 0 –1,430 weeks), 12 used cocaine (Mdn = 172 weeks, range = 0–1,496 weeks), 11 used hallucinogens (Mdn = 1 week, range = 0–156 weeks), 9 used amphetamines (Mdn = 1 week, range = 0 –364 weeks), 9 used opiates (Mdn = 1 week, range = 0 –1,673 weeks), 7 used benzodiazepines (Mdn = 1 week, range = 0–520 weeks), 5 used inhalants (Mdn = 0 week, range = 0 –6 weeks), and 4 used hypnotics (Mdn = 0 week, range = 0–520 weeks). Excluding prescribed methadone, during the 90 days prior to baseline, participants used a mean of 1.6 (range = 0 –3) types of substances and used substances on 58% (SD = 36.5) of days. During this period, one participant on methadone was otherwise abstinent; 12 participants drank alcohol (median drinks per drinking day = 3, range = 0 –17), 9 used cannabis, 4 used cocaine, 1 used benzodiazepines, and 1 used opiates. All participants had at least one nonsubstance use DSMIV Axis I diagnosis at baseline (M = 2.1, range = 1–5), including MDD (n = 12), PTSD (n = 11), panic disorder (n = 4), generalized anxiety disorder (n = 4), and specific phobia (n = 1). Eleven participants were on psychotropic medication during study participation: 10 on antidepressants, 3 on benzodiazepines, 3 on neuroleptics, 2 on mood stabilizers, and 1 on nonbenzodiazepine sleep medication. In addition to the three participants on methadone who were enrolled in public methadone maintenance programs, two participants recruited from our low-income community
clinic continued to receive supportive counseling during study participation and one participant was enrolled in a residential program for mothers with addictions. All participants judged grief to be their primary problem, with the exception of their SUDs. 3.1.2. Comparison of treatment completers and noncompleters Eight participants (five men and three women) completed the treatment, whereas six women and two men were noncompleters. The mean number of sessions for noncompleters was 9.3 (SD = 5.5, range = 1–15). One participant dropped out because of unwillingness to continue grief-focused procedures, and three dropped out for unknown reasons. Two participants were withdrawn for medical reasons (abnormal electrocardiogram, gastrointestinal disorder), and one was withdrawn for failure to attend treatment sessions. One participant was withdrawn for worsening substance use and depression after nine sessions. This participant was one of two enrolled early in the study whose condition worsened after telling the story of the death during the first treatment session. The other participant was able to restabilize and successfully complete the treatment. Nonetheless, after these events, we changed the protocol such that the story was not told until after the patient completed the initial treatment phase; no further case of worsening occurred. Two completers each had one positive breathalyzer test; no noncompleter had positive breathalyzers. The two sessions in question were rescheduled, and we ensured that the patient was seen home safely, with no further complication. Although higher proportions of women and those grieving over violent deaths were noncompleters, there was no statistically significant relationship between completion and sex (71% males vs. 37% females; h = .78, p = .31) or type of death (67% nonviolent vs. 29% violent; h = .78, p = .31). Among participants on antidepressants, six completed treatment and four did not, whereas two participants not on antidepressants completed treatment and four did not ( p = .61). Although the difference was not significant, completers had a lower proportion of abstinent days at baseline (32% vs. 53%; p = .51). 3.2. Treatment outcomes 3.2.1. Symptom scores Grief, depression, and substance use symptom outcomes are summarized in Table 1. Significant pretreatment-to-posttreatment reductions were found in ICG scores in completers (M = 30.9, SD = 15.4, S = 18, p = .01) and intent-to-treat analysis (M = 15.3, SD = 19.7, S = 48, p = .01), with effect sizes of 2.01 and 0.78, respectively. In a comparable CGT pilot study (Shear, Frank, et al., 2001), mean reductions in ICG scores were 22.8 (SD = 13.14, z = 3.11, p = .002) among
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Table 1 Scores on measures of grief, depression, and substance use in CGSUT a participants ICG Participant group
Pretreatment
Completer (n = 8) M 49.0 SD 9.8 Noncompleter (n = 8)b M 46.1 SD 9.7 Intent-to-treat (n = 16) M 47.6 SD 9.5
BDI Posttreatment
D
TLFB percent days abstinent
Initial session
Final session
D
Pretreatment
In treatment
D
18.1 14.0
30.94 15.4
26.5 12.7
11.0 10.9
15.54 5.5
32.0 26.8
58.5 33.7
26.544 29.8
46.4 8.2
0.3 6.5
27.0 10.1
26.6 13.8
0.4 7.3
52.6 43.5
67.0 31.0
14.4 55.4
32.3 18.3
15.34 19.7
26.8 11.1
18.8 14.5
7.94 10.0
42.3 36.5
62.8 31.6
20.444 43.4
a
Manual-guided individual outpatient treatment conducted in 24 sessions over approximately 6 months. Last observation carried forward. 4 p = .01. 44 p b .05.
b
completers and 16.9 (SD = 19.99, z = 3.51, p b .001) in intent-to-treat analysis, with effect sizes of 2.19 and 1.45, respectively. BDI scores showed corresponding reductions for both completer (M = 15.5, SD = 5.5, S = 18, p = .01) and intentto-treat (M = 7.9, SD = 10.0, S = 40, p = .01) groups, with effect sizes of 2.82 and 0.79, respectively. Again, this was similar to reductions in BDI scores in the CGT pilot study for the completer (M = 13.1, SD = 10.19, z = 2.98, p = .003) and intent-to-treat (M = 10.4, SD = 9.93, z = 3.44, p = .001) groups, with effect sizes of 1.80 and 1.16, respectively. TLFB percent days abstinent from all substances increased significantly among the completer (M = 26.5, SD = 29.8, S = 15, p = .04) and the intent-to-treat (M = 20.4, SD = 43.4, S = 39, p = .04) groups. Effect sizes were 0.89 and 0.47, respectively. Among completers, mean reduction in ICG score was 30.8 for patients on antidepressants (n = 6) and 31.0 for patients not on antidepressants (n = 2). In intent-to-treat analysis, mean reduction in ICG score was 19.1 (SD =20.3) for the 10 participants on antidepressants and 9.0 (SD = 18.7) for the 6 participants not on antidepressants ( p = .31). 3.2.2. Cravings A significant negative slope was found in the mixedmodel analysis of the intent-to-treat sample, such that average cravings decreased over time. Mean craving score was 2.2 at treatment initiation, whereas the predicted value at treatment completion was 1.6, F (1, 13) = 5.30, p = .04, d = 1.30.
4. Discussion Complicated grief is a chronic and debilitating condition. The identification of this postloss syndrome led to the development of a targeted efficacious treatment, but the treatment was previously unavailable to those with SUDs, despite the long-recognized prominence of grief problems among
them. Our pilot study represents the first effort at establishing the feasibility of delivering CGT in this population. This study is limited by its small number of participants and its open treatment design. In addition, the first author, who was the primary developer of the adapted treatment, administered all treatments. For these reasons, the effect sizes we observed are likely to overestimate those we would see in a larger randomized trial that controls for effects of time and attention, as well as therapist effects. Nevertheless, the results, although preliminary, are promising and suggest that a grief-focused treatment, combined with MI and skills building for emotion coping and communication, can feasibly be delivered to patients with extensive substance use histories who are actively using substances upon treatment entry. The large effect sizes for changes in griefrelated symptoms and the concomitant improvement in substance use and cravings support the idea that this treatment is of potential benefit. Clearly, it is important to be cautious when using a treatment that is emotionally evocative in persons with SUDs. We took several steps to address this concern. We added a five-session coping skills component to our adapted treatment, began revisiting exercises only with patients judged ready for them, and monitored cravings at each session. We were flexible in our use of evocative procedures, allowing patients to proceed at a pace they found manageable. When we discovered, in two early cases, that telling the story of the death in the first session was followed by worsening of substance use, we changed our procedure such that their story was not told until after coping skills had been taught; we saw no further case of deterioration. Only 50% of the participants completed the treatment. Although this rate was lower than that desirable, it is similar to that found in our pilot study on CGT that excluded persons with SUDs. Other SUD treatment trials have recorded high rates of dropout (e.g., completers = 28%; Crits-Cristoph et al., 1999). In their open pilot study of an exposure-based treatment for PTSD and cocaine dependence,
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Brady et al. (2001) reported a completion rate of 39%. Nonetheless, efforts to increase treatment retention in CGSUT should be an important part of future development work. Our sample was heterogeneous where choice of substance and pretreatment severity of substance use were concerned, and we assessed substance use outcomes solely through the TLFB interview and weekly cravings ratings. Concomitant psychotropic medication use was also heterogeneous, and several participants received psychosocial care outside the study. Future studies would benefit from drawing a sample from a more homogeneous population, using a range of measures of substance use severity and outcome (including biologic measures; i.e., urinalysis and breathalyzer testing), and controlling for the use of antidepressant medication and external psychosocial treatment. Follow-up assessments are also needed to determine whether gains in complicated grief symptoms are durable and whether decreases in substance use, such as those found in our sample, continue following treatment, especially among those people who attained a large reduction in complicated grief symptoms. In summary, these findings provide support for further research utilizing our adaptation of CGT for persons with SUDs. Development and dissemination of an efficacious treatment for complicated grief in persons with SUDs would have the potential to alleviate suffering and improve substance use treatment outcomes in those who suffer from this condition.
Acknowledgments This work was supported by grants from the National Institute of Mental Health (R01 MH60783 and P30 MH30915) and the National Institute on Drug Abuse (Administrative Supplement MH60783). We are grateful to Krissa Caroff, B.A., Jacqueline Fury, B.A., and Randi Taylor, Ph.D., for their assistance in the conduct of this study.
References Accordino, M. P., & Guerney, B. G., Jr. (2001). The empirical validation of Relationship Enhancement Couple and Family Therapy. In D. J. Cain, & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 403 – 442). Washington, DC7 American Psychological Association. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC7 APA. Back, S. E., Dansky, B. S., Carroll, K. M., Foa, E. B., & Brady, K. T. (2001). Exposure therapy in the treatment of PTSD among cocaine dependent patients: Description of procedures. Journal of Substance Abuse Treatment, 21, 35 – 45. Beck, A. T. (1978). Depression inventory. Philadelphia7 Center for Cognitive Therapy.
Bellwood, L. R. (1975). Grief work in alcoholism treatment. Alcohol Health and Research World, Exp Issue, 8 – 11. Blankfield, A. (1982/1983). Grief and alcohol. American Journal of Drug and Alcohol Abuse, 9, 435 – 446. Boelen, P. A., & van den Bout, J. (2005). Complicated grief, depression, and anxiety as distinct postloss syndromes: A confirmatory factor analysis study. American Journal of Psychiatry, 162, 2175 – 2177. Boelen, P. A., van den Bout, J., & de Keisjer, J. (2003). Traumatic grief as a disorder distinct from bereavement-related depression and anxiety: A replication study with bereaved mental health care patients. American Journal of Psychiatry, 160, 1339 – 1341. Brady, K. T., Dansky, B. S., Back, S. E., Foa, E. B., & Carroll, K. M. (2001). Exposure therapy in the treatment of PTSD among cocainedependent individuals: Preliminary findings. Journal of Substance Abuse Treatment, 21, 47 – 54. Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843 – 861. Charney, D., Paraherokis, A., Negrete, J., & Gill, K. (1998). The impact of depression on the outcome of addictions treatment. Journal of Substance Abuse Treatment, 15, 123 – 130. Chen, J. H., Bierhals, A. J., Prigerson, H. G., Kasl, S. V., Mazure, C. M., & Jacobs, S. (1999). Gender differences in the effects of bereavementrelated psychological distress in health outcomes. Psychological Medicine, 29, 367 – 380. Crits-Cristoph, P., Siqueland, L., Blaine, J., Frank, A., Luborsky, L., Onken, L. S., et al. (1999). Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56, 493 – 502. Dodge, R., Sindelar, J., & Sinha, R. (2005). The role of depression symptoms in predicting drug abstinence in outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 28, 189 – 196. Fals-Stewart, W., O’Farrell, T. J., Freitas, T. T., McFarlin, S. K., & Rutigliano, P. (2000). The Timeline Followback reports of psychoactive substance use by drug-abusing patients: Psychometric properties. Journal of Consulting and Clinical Psychology, 68, 134 – 144. First, M. B., Spitzer, L., Gibbon, M., & Williams, J. B. W. (1996). Structured clinical interview for DSM IV Axis I disorders. New York7 New York State Psychiatric Institute. Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive–behavioral therapy for PTSD. New York7 Guilford. Greenberg, L., & Paivio, S. (1997). Working with emotions in psychotherapy. New York7 Guilford. Harkness, K. L., Shear, M. K., Frank, E., & Silberman, R. A. (2002). Traumatic grief treatment: Case histories of 4 patients. Journal of Clinical Psychiatry, 63, 1113 – 1120. Hasin, D., Liu, X., Nunes, E., McCloud, S., Samet, S., & Endicott, J. (2002). Effects of major depression on remission and relapse of substance dependence. Archives of General Psychiatry, 59, 375 – 380. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91 – 111. Horowitz, M. J., Siegel, B., Holen, A., & Bonanno, G. A. (1997). Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry, 154, 904 – 910. Kranzler, H. R., Del Boca, F. K., & Rounsaville, B. J. (1996). Co-morbid psychiatric diagnosis predicts three-year outcomes in alcoholics: A posttreatment natural history study. Journal of Studies on Alcohol, 57, 619 – 626. Latham, A. E., & Prigerson, H. G. (2004). Suicidality and bereavement: Complicated grief as psychiatric disorder presenting greatest risk for suicidality. Suicide & Life-Threatening Behavior, 34, 350 – 362. Li, J., Laurson, T. M., Precht, D. H., Olsen, J., & Mortensen, P. B. (2005). Hospitalization for mental illness among parents after the death of a child. New England Journal of Medicine, 352, 1190 – 1196. 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, 637 – 662.
A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211 McLellan, A. T., Luborsky, L., Woody, G. E., O’Brien, C. P., & Druley, K. A. (1983). Predicting response to alcohol and drug abuse treatments: Role of psychiatric severity. Archives of General Psychiatry, 40, 620 – 625. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., III, & Brent, D. (2004). Traumatic grief among adolescents exposed to a peer’s suicide. American Journal of Psychiatry, 161, 1411 – 1416. Melhem, N. M., Rosales, C., Karageorge, J., Reynolds, C. F., III, Frank, E., & Shear, M. K. (2001). Comorbidity of Axis I disorders in patients with traumatic grief. Journal of Clinical Psychiatry, 62, 884 – 887. Miller, W. R., & Rollnick, R. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York7 Guilford. Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. Journal of the American Medical Association, 291, 1887 – 1896. Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., Weideman, R., McCallum, M., Azim, H. F., et al. (2003). Differentiating symptoms of complicated grief and depression among psychiatric outpatients. Canadian Journal of Psychiatry, 48, 87 – 93. Ott, C. H. (2003). The impact of complicated grief on mental and physical health at various points in the bereavement process. Death Studies, 27, 249 – 272. Ouimette, P., Moos, R. H., & Finney, J. W. (2003). PTSD treatment and 5year remission among patients with substance use and posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 71, 410 – 414. Ouimette, P. C., Brown, P. J., & Najavits, L. M. (1998). Course and treatment of patients with both substance use and posttraumatic stress disorder. Addictive Behaviors, 23, 785 – 795. Pitman, R. K., Altman, B., Greenwald, E., Longpre, R. E., Macklin, M. L., Poire, R. E., et al. (1991). Psychiatric complications during flooding therapy for posttraumatic stress disorder. Journal of Clinical Psychiatry, 52, 17 – 20. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., III, Shear, M. K., Day, N., et al. (1997). Traumatic grief as a risk factor for mental and physical morbidity. American Journal of Psychiatry, 154, 616 – 623. Prigerson, H. G., Bierhals, A. J., Kasl, S. V., Reynolds, C. F., III, Shear, M. K., Newsom, J. T., et al. (1996). Complicated grief as a disorder distinct from bereavement-related depression and anxiety: A replication study. American Journal of Psychiatry, 153, 1484 – 1486. Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., III, Anderson, B., Houck, G. S., et al. (1995). Complicated grief and bereavement-related depression as distinct disorders: Preliminary empirical validation in elderly bereaved spouses. American Journal of Psychiatry, 152, 22 – 30.
211
Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F., III, Bierhals, A. J., Newsom, J. T., Fasiczka, A., et al. (1995). Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59, 65 – 79. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Kasl, S. V., Maciejewski, P. K., Silverman, G. K., et al. (2000). Grief and its relation to posttraumatic stress disorder. In D. Nutt, & J. R. T. Davidson (Eds.), Post traumatic stress disorders: Diagnosis, management, and treatment (pp. 163 – 186). New York7 Martin Dunitz. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F., Maciejewski, P. K., Davidson, J. R. T., et al. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, 67 – 73. Shear, M. K., Frank, E., Foa, E., Cherry, C., Reynolds, C. F., III, Vander Bilt, J., et al. (2001). Traumatic grief treatment: A pilot study. American Journal of Psychiatry, 158, 1506 – 1508. Shear, K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated grief: A randomized controlled trial. Journal of the American Medical Association, 293, 2601 – 2608. Shear, M. K., Zuckoff, A., & Frank, E. (2001). The syndrome of traumatic grief. CNS Spectrums, 6, 339 – 346. Shear, K., Zuckoff, A., Frank, E., Daley, D. C., Cornelius, J., Houck, P., et al. (2005). Complicated grief and substance use in methadone maintenance patients: A survey study. Poster presented at the 67th annual scientific meeting of the College on Problems of Drug Dependence, Orlando, FL. Shear, M. K., Zuckoff, A., Melhem, N., & Gorscak, B. J. (in press). The syndrome of traumatic grief and its treatment. In L. A. Schein, H. I. Spitz, G. M. Burlingame, & P. R. Muskin (Eds.), Psychological effects of catastrophic disasters: Group approaches to treatment. New York7 Haworth Press. Silverman, G. K., Jacobs, S. C., Kasl, S. V., Shear, M. K., Maciejewski, P. K., Noaghiul, F. S., et al. (2000). Quality of life impairments associated with diagnostic criteria for traumatic grief. Psychological Medicine, 30, 857 – 862. Sobell, L. C., & Sobell, M. B. (1996). Timeline Followback user’s guide: A calendar method for assessing alcohol and drug use. Toronto, Ontario, Canada7 Addiction Research Foundation. Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197 – 224. Triffleman, E., Carroll, K., & Kellogg, S. (1999). Substance dependence posttraumatic stress disorder therapy: An integrated cognitive–behavioral approach. Journal of Substance Abuse Treatment, 17, 3 – 14. Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York7 Basic Books.