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Bryant and colleagues randomized 80 adults with prolonged grief disorder. Everyone got ten sessions of group CBT. The only difference was whether four individual sessions used exposure or supportive counselling.

At six months, 14.8% of the exposure group still met criteria for prolonged grief disorder. In the group that got everything except exposure, it was 37.9%.

A 2025 analysis pooling 40 trials and 4,566 participants found that the treatments ranking highest all contained an exposure element.

Eisma and colleagues randomized 47 bereaved adults to internet-delivered exposure, internet-delivered behavioural activation, or a waiting list. Both active treatments reduced complicated grief symptoms and rumination compared with the waiting list.

Later work found rumination sits in a chain with hopelessness and behavioural avoidance in predicting how people do after a bereavement.

The systematic review on this covered 85 studies and 12,294 participants. It found high rates of sleep disturbance after a bereavement, grief intensity tracking with sleep difficulty, and worse rates in complicated grief, particularly alongside depression.

The same review found that grief therapy improved sleep somewhat, but that no intervention study had ever targeted sleep problems in bereaved people directly. That gap is why this card leans on the rumination technique.

Confronting avoided situations is a formal part of Complicated Grief Treatment. That protocol beat interpersonal psychotherapy 51% to 28%, with a number needed to treat of 4.3, and later outperformed antidepressant medication.

Boelen and colleagues found that CBT including exposure beat supportive counselling, and that the order mattered. Starting with exposure did better than starting with supportive work.

Norton and Gino ran a series of experiments where people who performed a ritual after a loss reported less grief than people who didn't. This held even for rituals the researchers invented on the spot.

One limit to know about. This was laboratory work on induced and recalled loss, not a clinical trial in bereaved people. How large the effect is in real bereavement isn't known. It's here because it's a real experimental finding that lines up with something nearly every culture already does.

These beliefs are a measured mechanism rather than a side effect. In Bryant's trial, the exposure condition produced greater improvement specifically in negative appraisals (p = .009), alongside grief severity and daily functioning.

In a 2024 trial of 100 adults, grief-focused CBT beat mindfulness-based cognitive therapy with a large between-group effect of around 0.8, and produced bigger reductions in grief-related thinking in particular.

The 2025 analysis of 40 trials and 4,566 participants ranked psychoeducation with social support at SMD = −1.86, tied for the highest of any treatment examined.

In older adults, complicated grief group therapy beat standard group therapy in a randomized trial. Nearly half of those who completed it reached clinically significant improvement, and all completers finished below the threshold that would have qualified them for the study in the first place.

Physical activity has its own review covering 25 studies, with reductions in depression, anxiety and post-traumatic stress symptoms. Participants described it as a way to express emotion, get away from the grief for a while, and be around people.

The landmark study followed 205 people from before their spouse died through 6 and 18 months afterward. The patterns were: resilient 45.9%, chronic grief 15.6%, common grief 10.7%, depressed-improved 10.2%, chronic depression 7.8%.

Nearly half followed a resilient course. The researchers noted that what people think of as "typical" grief was actually fairly uncommon.

Formal prolonged grief disorder affects roughly 4.7% of bereaved people under DSM-5-TR criteria and 5.4% under ICD-11 criteria.

These are observational studies rather than trials, which is why this card describes what's normal instead of prescribing a technique.

A 2025 meta-analysis of 13 randomized controlled trials found expressive writing reduced grief (Hedges' g = 0.388) and depression (g = 0.308). Small effects, and the authors say so plainly.

What moves the number is structure. More sessions reached g = 0.583. Therapist feedback reached g = 0.679. One-off unguided writing is the weakest version of this.

In suicide bereavement specifically, death-related writing tasks beat control writing tasks on suicide-specific aspects of grief.

The pet bereavement literature documents this most clearly. Attachment intensity predicts grief intensity, disenfranchised grief complicates mourning, and online communities become significant sources of support precisely because in-person permission is missing.

This literature is descriptive and qualitative, though. There are no randomized trials of interventions for disenfranchised grief.

The suicide bereavement review found that the interventions showing promise involved the bereaved person's social environment and ran as a series of facilitated sessions, which is the tested version of "find people who understand."