November/December 2018

Innovations in Geriatrics: Treating Persistent Grief With Accelerated Resolution Therapy
By Harleah G. Buck, PhD, RN, FPCN, FAAN
Today's Geriatric Medicine
Vol. 11 No. 6 P. 28

Approximately 43.5 million informal caregivers provide $470 billion per year in services to family and friends.1,2 This amount rivals the cost of formal, paid home care services and Medicaid spending combined.2 Thirty-four percent of these unsung heroes of health care are older than 65 themselves.1 The death of their care recipients are traumatic events that affect the survivors in expected and unexpected ways. The finality and enduring sense of loss can be debilitating, especially for older adults losing a spouse after many years of marriage or the unexpected event of an adult child preceding them in death.

When the survivor's grief extends for more than 12 months, the condition can be deemed chronic, and mental health therapy may be warranted. An estimated 10 million Americans suffer from persistent, complicated grief, also known as "prolonged grief" or "persistent complex bereavement disorder."3

In May 2018, grief was reclassified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the definitive and widely accepted industry treatment guideline for mental health conditions published by the American Psychiatric Association (APA).

DSM-5 removed the bereavement exclusion for major depressive episodes. Previously, a major depressive episode that came after the death of a loved one and lasted less than two months was not classified as a major depressive episode. This change was controversial but accepted by the APA given the lack of evidence showing that major depression post bereavement differs from other major depressive disorders and the concurrent risk of suicide. This means there's no longer a clinical basis for treating grief differently than other traumas that can trigger depression. It also acknowledges that symptoms may last for an extended period of time.4

Persistent grief disproportionately affects older adults.5,6 More than 70% of older adults will lose someone close to them in a given 30-month period.7,8 The survivors may feel shocked or dazed by their losses, have difficulty accepting them, and find themselves getting stuck thinking about the meaning of the loss, its causes, or its consequences.9 Persistent grief robs its victims of their enjoyment of life. It also can affect physical conditions such as blood pressure and cardiovascular disease, weaken immune response, and contribute to sleeping difficulties—all of which can lead to greater health consequences.

Simply put, persistent grief can result in serious health problems.10

Treating Grief Like Trauma
When grief extends beyond a year, traditional methods of psychotherapy and group support may have limited benefit. When grief counseling has been tied to hospice care for the lost care recipient, sources of insurance such as Medicare may no longer be available after 12 months.

For these reasons, there's a significant public health need for new therapies that effectively treat persistent grief, ideally using a brief treatment protocol. As a result, I'm teaming with University of South Florida colleague Kevin E. Kip, PhD, an international expert on Accelerated Resolution Therapy (ART), to conduct a clinical trial to examine whether ART is a successful, brief treatment that can be used to address the symptoms of persistent grief in caregivers.

Earlier this year, we announced the launch of a two-year National Institutes of Health (National Institute on Aging)–funded study to examine the effectiveness of ART in treating individuals aged 60 and older who are suffering from persistent grief. In total, the study will examine the impact of ART on persistent grief, psychological trauma, and depressive symptoms.

Fifty older adults who exhibit current symptoms of persistent grief and who had an immediate family member die more than 12 months ago after spending time in hospice care will receive ART. To be enrolled in the study, all participants will be assessed by a qualified clinician.

What Is ART?
Developed by Laney Rosenzweig, MS, LMFT, in 2008, ART is an evidence-based, nonpharmacological therapy that aims to change the traumatic and distressing memories and images stored in the brain through a combination of desensitization and memory reconsolidation.11 ART has been tested successfully for the treatment of depressive symptoms, trauma, and stress.11-14

The therapy's distinct features include the use of horizontal eye movements and memory reconsolidation, which have been shown to provide effective relief from the strong physical and emotional reactions associated with posttraumatic stress disorder (PTSD) and other traumas in as few as one to five sessions, with the average being four sessions.15

Unlike traditional "talk" therapies used to treat symptoms of grief, ART focuses on two things: desensitizing the patient to the signs of physical distress such as fast heartbeat or nausea that emerge when thoughts of the death of the loved one arise and reimagining the past with the loved one in a more positive way.16

The therapy's desensitization is achieved by asking the client to first recognize and focus on the uncomfortable physical feelings and sensations associated with recall of the death while simultaneously tracking with eye movements the clinician's hand as it moves left to right. This use of eye movements reduces the clients' current level of distress and the emergence of physical sensations when they think about the death in the future.

The next step is to bring up the haunting memories and reframe them in a more positive manner. During this process, a therapist might direct the clients to recall positive memories of what life was like before the loved ones were ill and to imagine interacting with the lost loved ones in a positive way, such as saying goodbye and expressing their love. The goal of this activity is to add positive material to the existing memory through the process of memory reconsolidation.

After the physical desensitization and memory reconsolidation steps are completed, successfully treated clients no longer experience the troubling memories and symptoms of persistent grief.

Why Might ART Treat Grief?
There's substantial burden and challenges in treating persistent grief in this older population. Given somewhat similar symptom patterns in PTSD and persistent grief (intrusive thoughts, avoidance, and emotional numbing), our research team thought persistent grief might respond similarly to PTSD treatments.17

Clinicians' anecdotal reports suggest that ART can help patients with PTSD, phobias, obsessive-compulsive disorder, addictions, anxiety, depression, grief, and other psychiatric conditions. Also, the therapy's effectiveness and ability to reduce compassion fatigue in the clinician has contributed to high provider satisfaction rates. Studies have shown that by limiting exposure to distressful memories, the therapy is emotionally easier on both the patient and the therapist than are other therapies.18

The therapy's proven effectiveness in treating PTSD symptoms inspired restaurateur and philanthropist Chris T. Sullivan to form ART International, a nonprofit organization dedicated to making ART more widely available to individuals in need of successful treatment options. To expand the reach of this therapy, ART International has looked specifically to increase the number of clinicians trained in this treatment. To accomplish this, the nonprofit aims to host more than 100 training sessions in different cities throughout the country for licensed mental health professionals.

While ART has not been previously studied as a therapy for persistent grief, Kip and I are encouraged by its promise. In a recent paper, Kip presented an ART protocol that contains the core therapeutic elements and aligns closely with the current VA and Department of Defense Clinical Practice Guideline.

ART has a plausible theoretical rationale and an evolving empirical research base that includes four studies with peer-reviewed publications, one of which was a randomized controlled trial. These features, along with the brevity of the treatment protocol, no requirement for narration, and high provider satisfaction rates, support the use of ART as a first-line PTSD treatment modality for active duty and veteran military personnel as well as for similar syndromes such as persistent grief.19

ART has the potential to be a nonpharmacological, cost-effective, and time-saving solution for grief-stricken caregivers. We can't afford to replace the care that informal caregivers provide. We need to support them so that they can continue to care for other family members or friends. Kip and I look forward to the results of this study. If they are promising with respect to effective treatment of persistent grief, it could lead to a larger study involving multiple sites to get a wider sampling of clients and obtain a more precise estimate of ART's benefits.

— Harleah G. Buck, PhD, RN, FPCN, FAAN, is an associate professor, coordinator of chronic illness issues, and researcher with 10 years of experience on US Federal, foundation, and industry-funded studies. Buck has more than 30 years' clinical experience and more than 50 peer-reviewed publications. In 2014, she was inducted as a Fellow in Palliative Care Nursing and in 2015 honored as a "Face of Hospice and Palliative Nurses Association." She most recently cochaired the joint American Nurses Association/Hospice and Palliative Nurses Association Professional Issues Panel.

References
1. National Alliance for Caregiving; AARP Public Policy Institute. Caregiving in the U.S. http://www.caregiving.org/wp-content/uploads/2015/05/2015_CaregivingintheUS_Final-Report-June-4_WEB.pdf. Published June 2015.

2. Reinhard SC, Feinberg LF, Choula R, Houser A; AARP Public Policy Institute. Valuing the invaluable: 2015 update. https://www.aarp.org/content/dam/aarp/ppi/2015/valuing-the-invaluable-2015-update-new.pdf. Published July 2015.

3. Overview. The Center for Complicated Grief website. https://complicatedgrief.columbia.edu/professionals/complicated-grief-professionals/overview/

4. Pies RW. The bereavement exclusion and DSM-5: an update and commentary. Innov Clin Neurosci. 2014;11(7-8):19-22.

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

6. Newson RS, Boelen PA, Hek K, Hofman A, Tiemeier H. The prevalence and characteristics of complicated grief in older adults. J Affect Disord. 2011;132(1-2):231-238.

7. Intriago J. Prolonged grief disorder (PGD) in the elderly. SeniorsMatter.com website. http://seniorsmatter.com/prolonged-grief-disorder/. Published July 8, 2017.

8. Boelen PA, Prigerson HG. The influence of symptoms of prolonged grief disorder, depression, and anxiety on quality of life among bereaved adults. Eur Arch Psychiatry Clin Neurosci. 2007;257(8):444-452.

9. What is prolonged grief? Traumatic Stress Clinic website. http://www.traumaticstressclinic.com/what-is-prolonged-grief/ 

10. Carey IM, Shah SM, DeWilde S, Harris T, Victor CR, Cook DG. Increased risk of acute cardiovascular events after partner bereavement: a matched cohort study. JAMA Intern Med. 2014;174(4):598-605.

11. Kip KE, Rosenzweig L, Hernandez DF, et al. Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD). Mil Med. 2013;178(12):1298-1309.

12. Kip KE, Elk CA, Sullivan KL, et al. Brief treatment of symptoms of post-traumatic stress disorder (PTSD) by use of Accelerated Resolution Therapy (ART®). Behav Sci (Basel). 2012;2(2):115-134.

13. Kip KE, Hernandez DF, Shuman A, et al. Comparison of Accelerated Resolution Therapy (ART) for treatment of symptoms of PTSD and sexual trauma between civilian and military adults. Mil Med. 2015;180(9):964-971.

14. Kip KE, Rosenzweig L, Hernandez DF, et al. Accelerated Resolution Therapy for treatment of pain secondary to symptoms of combat-related posttraumatic stress disorder. Eur J Psychotraumatol. 2014;5.

15. Effective & efficient post-traumatic stress treatment. ART International website. https://artherapyinternational.org/clinicians/

16. USF Health researchers team up to study effectiveness of novel therapy for prolonged grief. University of South Florida Health website. https://hscweb3.hsc.usf.edu/nursingnews/usf-health-researchers-team-up-to-study-effectiveness-of-novel-therapy-for-prolonged-grief/ . Published April 23, 2018.

17. O'Connor M. A longitudinal study of PTSD in the elderly bereaved: [corrected] prevalence and predictors. Aging Ment Health. 2010;14(3):310-318.

18. Waits W, Marumoto M, Weaver J. Accelerated Resolution Therapy (ART): a review and research to date. Curr Psychiatry Rep. 2017;19(3):18.

19. Kip KE, Diamond DM. Clinical, empirical, and theoretical rationale for selection of Accelerated Resolution Therapy for treatment of post-traumatic stress disorder in VA and DoD facilities [published online April 4, 2018]. Mil Med. doi: 10.1093/milmed/usy027.