The Effectiveness of Integrated Group Therapy on Prolonged Grief Disorder of Bereaved People from COVID-19 Randomized Controlled Trial

Abstract

This study aimed to evaluate the integrated cognitive-behavioral group therapy and Gestalt empty chair technique on bereaved individuals with COVID-19-caused PGD (prolonged grief disease). Thirty-six patients with PGD resultant from COVID-19 were randomly assigned intervention and control groups. The intervention group underwent 16 90-minute integrated group therapy sessions twice a week. Both groups completed the BDI II depression, NAI anger, and GASP guilt scale before, after, and 2 months after the study’s conclusion. The intervention and control groups significantly differed in the depression, anger, and guilt indices after the therapeutic intervention (p < .001). This difference remained in the follow-up phase. Integrated group therapy in treating could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. This reduction in symptoms was also stable over time.

Introduction

The coronavirus has been the biggest pandemic since the Spanish influenza outbreak in 1918. Almost 6,500,000 people have died of this virus from 2019 to October 2022 (“Coronavirus 2019 Reported Cases and Deaths,” (Worldometer, 2022).

In America, it has been shown that every corona-resultant death leads to the grief of nine family members (Verdery et al., 2020). This statistic can escalate due to the intimacy of the family members in some eastern countries and the bereavement of intimate friends (Murphy, 2008). Accordingly, we can assert that this disease has made at least 58 million people suffer from corona-caused mourning. This number of grieving individuals can bring about a serious challenge to mental health worldwide. The management of these people is one of the most crucial responsibilities of psychologists.

In the past, grief and mourning were used interchangeably. However, today, with research in this field, grief is used as a concept to describe cognitive and emotional reactions, changes in performance, and behavior to the loss of a person (Schneider, 1980). In normal grief, at the beginning of loss, people usually experience extreme sadness, unfamiliar feelings, preoccupation with thoughts and memories of the deceased, difficulty concentrating, and a lack of interest in people and daily activities. Nevertheless, after a while (depending on the nature of the loss), the wounds start to heal, and the bereaved person finds a way to return to normal life. In contrast, prolonged grief is unresolved or traumatic and impairs the grieving person’s social functioning. People’s daily and social activities are disrupted by the thoughts and memories of the deceased, even after years (De Stefano et al., 2021). Recently, a new classification of grief called “Prolonged Grief Disorder” was added to the DSM-5 and ICD-11 to describe continuous and pervasive grief with longing and constant mental preoccupation for the deceased person (Szuhany et al., 2021). Based on the ICD-11 classification, PGD is usually accompanied by severe distress with feelings such as sadness, guilt, anger, denial, blame, difficulty accepting death, feeling like a part of oneself has been lost, inability to experience a positive mood, emotional numbness, and difficulty engaging with emotions. Also, PGD is usually manifested by the impairment of social activities, which goes beyond the social, cultural, or religious norms and damages the individual’s daily tasks (Eisma et al., 2020).

While PGD has been classified in ICD-11 and DSM-5TR, there are several differences between these classifications. The duration criteria for ICD-11 and DSM-5TR for the PGD are 6 months and 12 months, respectively. Also, while the DSM-5TR has 10 diagnosis criteria, the ICD-11 has two more criteria (denial and the inability to experience a positive mood). The feelings of despair, guilt, and anger are consistent in both the ICD-11 and DSM-5TR classifications. (Boelen, 2021; Eisma et al., 2020).

In their systematic reviews, Lundorf et al. and Dielantik et al. observed that the probability of prolonged grief is 9% among bereaved adults and 49% among individuals mourning in the face of unnormal deaths. However, higher statistics have been reported in non-western countries (Djelantik et al., 2020; Lundorff et al., 2017). Furthermore, the prolonged grief of the grieving adults due to COVID-19 has been reported at 37.8%, and there were no differences between the symptoms of individuals whose loved ones had died of the coronavirus longer or shorter than the past 6months (Tang & Xiang, 2021).

Furthermore, there is a direct relationship between guilt and an individual’s degree of grieving. In particular, concerning the grief arising from loved ones’ death due to COVID-19, the inability to take part in funerals, and the emerging feeling of guilt can be the primary factors giving rise to PGD in these people (Diolaiuti et al., 2021).

PGD could lead to avoidance behaviors, lack of control of emotions, and loss of social relationships (Stroebe et al., 2007). Prolonged grief in the long term could lead to negative outcomes that lower the life expectancy of the grieving person (Bowling, 1987; Song et al., 2019). The lack of treatment for PGD causes increased suicidal thoughts and activities, depression, and post-traumatic stress disorder (Latham & Prigerson, 2004). Suicidal thoughts and tendencies have been reported in 20–50% of PGD patients (Simon et al., 2007). Furthermore, prolonged grief disorder leads to physical and mental diseases like cancer, cardiovascular diseases, and substance abuse (Chen et al., 1999; Parisi et al., 2019; Stahl et al., 2016).

Based on Stroebe and Schut’s dual process of coping with bereavement, the person experiencing grief could go through periods of oscillation between confronting and avoiding the grief process due to the experience of loss or restoration-oriented stressors (Stroebe & Schut, 1999). Loss-oriented stressors refer to one’s feelings and experiences about losing a deceased person, such as anger, nostalgia, and longing for the return of the deceased person. Restoration-oriented stressors pertain to activities that are done to distract from the sadness and despair caused by bereavement and to deal with the stress and anxiety caused by the experience of loss (Fiore, 2021). Furthermore, the grief-to-personal growth model explains that the essence of grief remains the same, and it is the person and the life and new experiences that are added to it. Based on these models, successful treatment of grief includes gradually and continuously detaching from the decedent and building new relationships with others (Hogan & Schmidt, 2002). However, the novel treatment designs do not focus on reaching acceptance and terminating relationships with the deceased but rather on fitting feelings, awareness, and prior experiences with new realities associated with the loss (Eisma & Stroebe, 2021).

Different therapeutic methods, including CGT (Cognitive Grief Therapy) (Glickman et al., 2016), CBT (Cognitive Behavioral Therapy) (Breen et al., 2022), support group (Robinson & Pond, 2019), Gestalt (Seen et al., 2021), and pharmacotherapy are used for PGD treatment (Gang et al., 2021). It has been observed that the CBT treatment has a moderate and statistically significant effect on the alleviation of symptoms related to prolonged grief, such as anger, a feeling of guilt, and depression (Eisma & Stroebe, 2021; Szuhany et al., 2021). Individual and collective psychological therapies have been influential in grief treatment, and these effects stay until the follow-up phase (Wittouck et al., 2011).

Research has unveiled that group therapy can reduce the effects of undesirable experiences against the bereavement phenomenon rooted in the death of loved ones and, contrary to individual therapy, can impede the extensiveness of the social isolation, anger, and anxiety stemming from the death of these people (Para, 2009; Supiano et al., 2021).

There are different factors for accepting and adapting to the death of loved ones. One of the most significant factors constitutes the thoughts and beliefs of the person toward the death conditions of the decedent, feelings toward the decedent, relationships with and closeness to the decedent, and the attitudes of the person toward themself (Dolan et al., 2022). CBT is a method that can identify inefficient thoughts and feelings of people and examine and change them. Likewise, the embedded behavioral techniques of CBT could alter the lifestyle of grieving patients and therefore introduce restoration-oriented stressors in their daily life and help them complete their coping process.

Gestalt therapy, a humanistic-existential form of psychotherapy, is a grief treatment approach and emphasizes the personal responsibility and present experience of the person and the client-therapist relationships (Seen et al., 2021). Among the Gestalt therapy techniques, we can refer to the empty chair, which allows clients to discuss their blocked feelings and attitudes. This technique is used to help clients and reach unsolved feelings that make individuals experience difficulties (Rosner et al., 2011, 2015). Expressing suppressed feelings and examining individuals’ unmet needs can help them correctly perceive their feelings and behaviors (Greenberg et al., 2008; Roulston et al., 2018). Therefore, integrating the Gestalt empty chair technique and cognitive-behavioral interventions can be a helpful therapy for grieving individuals to express and alter their feelings. Also, Gestalt therapy has been shown to help with the personal growth of people, which, based on the grief-to-personal growth model, could help patients suffering from PGD cope with their grief (Leung et al., 2013). Combining CBT with Gestalt therapy will help patients change their destructive feelings and emotions towards the decedent and themselves by giving them a chance to say goodbye to the deceased (loss-oriented stressors). Also, this method alters their lifestyles using new behavioral habits, self-care, and personal growth (restoration-oriented stressors).

Numerous integrated therapies have examined prolonged grief; however, no study has so far, and some even addressed the integration of the group CBT and Gestalt empty chair has integrated some parts of Gestalt therapy, like the imaginal conversation, in their treatment method (Iglewicz et al., 2020). However, no integrated group therapy method has been evaluated on PGD or grief caused by COVID. Thus, the present research aimed to investigate the effectiveness of the integrated group CBT and Gestalt empty chair technique on individuals diagnosed with PGD and bereaved by the corona-caused death of their loved ones.

Methods

The inclusion criteria were the acquisition of >102 scores on the Grief Experience Questionnaire (GEQ-34) of Barrett and Scott (Barrett & Scott, 1989), the age range of 18–50, and the pass of >6 months from the corona-caused death of a loved person.

The exclusion criteria were substance abuse, simultaneously receiving psychiatric or pharmaceutical therapies, and possessing psychosis histories or symptoms.

Participants

The sample size for our study was calculated using based on the results of the BDI-II score of the study by Lacasta-Reverte (Lacasta-Reverte & Cruzado, 2021) and type I error/α = 0.05 and Type II error/β = 0.2: $N=2\times {\left(\frac{1.96+0.845}{3.74}\right)}^2\times {5.43}^2=32.7$. The sample size was calculated as 33 patients.

Participants included 18–50-year-old bereaved adults losing their loved ones due to the coronavirus. These people whose PGDs were diagnosed by psychologists or psychiatrists in their first session and were referred to us via six clinics in Mashhad city. None of these patients had received any psychiatric or psychological treatments between the death of their loved ones and the start of our study. We interviewed the selected individuals, recorded their medical histories, and administered the GEQ-34 test. The GEQ-34 (Grief Experience Questionnaire) is a self-reported measure of bereavement, consisting of subscales such as guilt, trying to justify and cope, physical reactions, feelings of abandonment, personal or other judgments, and embarrassment. The GEQ-34 test score above 102 was chosen as a measure of prolonged grief disorder based on the study by Treml et al. (Treml et al., 2021).

From the patients referred to us, the individuals scoring >102 on the GEQ test and experiencing pathological grief symptoms for more than 6 months (based on the ICD-11 classification) were included in our study. Out of 58 patients, 8 were excluded due to using psychological drugs, 11 due to not acquiring >102 scores, and 3 due to the non-fit of the intervention hours with their programs. The remaining 36 participants filled out the consent form (nobody refused to sign the form), and, finally, 36 individuals were entered into the study. Table 1 provides the demographic characteristics of the participants. If during the study, the participants developed any psychosis symptoms, suicidal tendencies, or need to use any psychological drugs, they would be excluded from the study. They would be referred to their original clinician for an emergency visit.

Table 1.

Demographic Properties of Sample Group.

Measure	Number of Participants		Percentage of Participants for Each Group
	Control	Experimental	Control	Experimental
Participants	18	18	100	100
Age
18–30	4	3	22.23	16.67
30–40	8	9	44.44	50.00
40–50	6	6	33.33	33.33
Sex
Male	8	8	44.45	44.45
Female	10	10	55.55	55.55
Academic status
Elementary school	1	2	5.55	11.11
High school	2	1	11.11	5.55
Associate degree	5	5	27.78	27.77
Bachelor degree	6	7	33.33	38.89
Master degree	3	2	16.66	11.11
Doctorate degree	1	1	5.55	5.55
Identity of deceased
Spouse/partner	2	3	11.11	16.67
Parent	9	7	50.00	38.88
Sibling	2	3	11.11	16.66
Aunt/uncle	3	2	16.67	11.11
Grandparent	1	2	5.55	11.11
Close friend	1	1	5.55	5.55
Other	0	0	0	0
Time since death (months) [mean ± SD]
Control group		Experimental group
13.61 ± 15.34		12.73 ± 14.87

The participants were assigned to the experimental and control groups (18 per group) based on simple randomization through the www.randomizer.org site. Then, the experimental group was divided into two therapeutic groups (9 per group) to provide sufficient time for treatment. Both 9-subject groups (a total of 18 subjects) underwent a single treatment, and the control group received no intervention. Before the intervention, all 36 participants filled out Beck’s Depression Inventory-II, Novaco Anger Inventory (NAI), and Cohen’s Guilt and Shame Proneness (GASP) scale. Afterward, both 9-subject groups received 16 90-minute sessions of integrated therapy (Kim Paleg Grief Protocol, 2015 (Berghuis & Paleg, 2015)) twice a week. After the intervention, the experimental and control groups took the posttest and were followed up 2 months later (Figure 1). The patients in the control group also underwent integrated treatment after the study’s conclusion.

Figure 1.

Flowchart illustarting the study.

Instruments

Beck’s Depression Inventory

Beck’s Depression Inventory, built in 1961, consists of 21 questions comparing somatic, behavioral, and cognitive symptoms of depression and is scored based on a 5-point Likert scale (0–4) (Beck et al., 1961). It measures severe to mild depression. Its minimum and maximum scores, Cronbach alpha coefficient, and test-retest reliability equal 0, 63, 0.78, and 0.73, respectively. The validity and reliability of this questionnaire have been estimated at 0.70 and 0.77 in the Iranian context (García-Batista et al., 2018).

Novaco Anger Inventory

This inventory, built by Novaco in 1986, is a self-report scale consisting of 30 items that measure anger and aggression. It is scored based on a 5-point Likert scale with zero and 100 as its minimum and maximum scores. Individuals acquiring scores above the mean possess higher levels of aggression. The validity and reliability of this scale have been reported at 0.86 and 0.96, and its Cronbach alpha coefficient and test-retest reliability equal 0.86 and 0.73 (Jang, 2019).

Cohen’s Guilt and Shame Proneness scale

The Guilt and Shame Proneness (GASP) scale was designed by Cohen and Wolf in 2011. It is a self-report scale with 16 items identifying shame and guilt in two subscales of negative self-evaluation and withdrawal behaviors. The scale is scored based on a 5-point Likert scale, and its Cronbach alpha coefficient for reliability has been reported at 0.61 and 0.71 (Young et al., 2021).

Therapy

The grief-treating group therapy was implemented based on the group therapy protocol of Kim Paleg (2015), which was an integration of the cognitive-behavioral group therapy and the Gestalt empty chair technique. It was provided in 16 90-minute sessions held twice a week for 8 weeks. The group sessions consisted of nine members who participated in activities collectively. The treatment for both 9-person intervention groups was overseen by the same three-clinician team with at least 4 years of grief counseling experience. F.B, with a doctorate in counseling, was the facilitator; K.B, with a doctorate in counseling, acted as the assistant, and J.J, with a doctorate in psychology, was the supervisor of the group therapy. Table 2 displays the descriptions of the sessions.

Table 2.

The Curriculum for Integrated Group Therapy Sessions.

Sessions	Content
1	Share the story of the loss, including who was lost, when, and how the loss occurred
2	Describe the impact of the loss on work, family, and relationships
3	Verbalize an increased understanding of the components of grief as parts of a process that must be experienced in order to heal
4	Identify personal grief coping strategies, including the use of substances, and note those that may have interfered with the grieving process
5	Accept the need for antidepressant medication and follow through on a referral to a physician for an evaluation
6	Demonstrate the ability to ask for help in group and with significant others
7	Write a letter to the deceased person saying goodbye and expressing all the feelings experienced in the aftermath of the loss
8	Verbalize the impact of the changed identity resulting from the loss
9	Articulate a realistic picture of the lost person—both positive and negative—and of the relationship with that person, and identify ways of remembering the special qualities
10	Report an increase in self-nurturing activities
11	Develop a plan or ceremony to facilitate memorializing the lost person
12	Verbalize self-care plans to cope with anniversary reactions
13	Read books on the grief process and discuss their impact
14	Verbalize an acceptance of the unique style of grieving of others close to the deceased
15	Verbalize the desire to and beginning of the process of letting go of bitter blame for the loss of the significant other
16	Verbalize a resolution of feelings of guilt or regret over actions toward the lost loved one. (Using empty chair technique to facilitate members’ saying goodbye to the deceased and saying things that were left unsaid or asking for forgiveness for actions regretted)

Ethical Considerations

Before the study, the researchers held a session for the subjects and explained the research procedure and its ethical issues, such as voluntary intervention leave. Then, the participants completed the informed consent form and were ensured that their identities would be confidential before, during, and after the release of the results. This study was approved by the ethics committee of the Iranian National Institute for Medical Research Development (NIMAD) with the registration number 4002721.

Results

Table 3 displays the means and standard deviations (SD) of the examined variables in the experimental and control groups in the pre-intervention, post-intervention, and follow-up phases. According to the results of this table, the intervention group’s mean scores in the anger, depression, and guilt indices are more degressive than the control group, and this degression continues until the follow-up phase. The ANCOVA test was used for testing the hypotheses. However, before running the test, the researchers investigated its basic assumptions using the Kolmogorov-Smirnov test for normality of data distribution, Levene’s test of homogeneity, box plots for the absence of irrelative variables, Box M test for covariance, matrice’s homogeneity, and linear regression for a linear relationship between the covariate and dependent variable.

Table 3.

Mean and Standard Deviation for Depression, Anger and Shame.

	Experimental Group				Control Group
		Pre-test	Post-test	Follow-up	Pre-test	Post-test	Follow-up
BDI-II	M	42.39	35.44	32.94	34.94	32.50	33.00
	SD	9.54	10.47	10.22	12.64	10.03	10.42
NAI	M	73.44	51.88	48.88	68.88	66.11	66.77
	SD	10.77	17.46	17.06	11.08	13.93	15.02
GASP	M	24.67	16.00	15.00	18.44	15.44	16.55
	SD	11.89	12.44	10.59	8.36	9.73	9.51

Note. BDI-II = Beck Depression Inventory-Second Edition; NAI = novaco anger scale; GASP = guilt and shame proneness scale test.

After the realization of the assumptions, the ANCOVA test was run for the comparison of the experimental and control groups in the posttest and follow-up phases (Tables 4 and 5).

Table 4.

Analysis of Covariance Results for Depression, Anger and Shame Scores From the Post-Intervention Stage (Between Groups).

	SS	df	MS	F	Sig	Es
BDI-II	3666.80	1	3666.80	208.75	.00	0.69
NAI	5922.39	1	5922.39	76.19	.00	0.88
GASP	3178.27	1	3178.27	261.76	.000	0.86

Note. BDI-II = Beck Depression Inventory-Second Edition; NAI = novaco anger scale; GASP = guilt and shame proneness scale test; df = degrees of freedom; ES = Eta squared; MS = mean square; SS = sum of squares.

Table 5.

Analysis of Covariance Results for Depression, Anger and Shame Scores in Follow-up Phase.

	SS	df	MS	F	Sig	Es
BDI-II	2382.684	1	2382.684	63.295	.000	.657
NAI	4775.315	1	4775.315	39.283	.000	.543
GASP	2830.275	1	2830.275	150.602	.000	.820

Note. BDI-II = Beck Depression Inventory-Second Edition; NAI = novaco anger scale; GASP = guilt and shame proneness scale test; df = degrees of freedom; ES = Eta squared; MS = mean square; SS = sum of squares.

The results of Table 4 show that the intervention and control groups are significantly different in the depression (p < 0.00, f = 208.75), anger (p < .001, F = 76.19), and Shame (p < .001, F = 261.76) indices. Likewise, according to the results of Table 5, the difference between the two groups is also significant in the follow-up phase in the depression (p < .001, F = 63.29), anger (p < .001, F = 39.28), and guilt (p < .001, F = 150.60).

Discussion

After treatment, the intervention group showed lower scores for anger, depression and guilt and these results remained until the follow-up. These results show that integrated group therapy could be a promising approach for lessening the PGD symptoms, such as depression, anger, and feeling of guilt among bereaved individuals who have lost their loved ones because of the Corona Virus. Concerning the alleviation of depression symptoms, our findings are in line with the results of studies conducted by other on the subject (Boelen et al., 2007; Bryant et al., 2014; Bryant et al., 2017; Roberts et al., 2019; Rosner et al., 2015). Although the main reasons for these changes are unknown, we can claim that those individuals get acquainted with one another in integrated group therapy, learn effective social skills, and test them in the group. Group therapy aims to make individuals come to a common experience of grief, reduce the isolation stemming from their avoidance behavior and limited social support, and discover opportunities for exchanging support (Schuster et al., 2017). Likewise, in integrated group therapy, individuals decrease their depression by doing daily enjoyable activities, performing respiratory exercises, receiving cognitive restructuring techniques, and challenging and changing negative coping beliefs (107). Challenging group members, repeating exercises in the group, and witnessing positive impacts on others encourage them to continue doing these activities. In a study, Thimm et al. showed that group therapy decreased depression symptoms by 45% (Thimm & Antonsen, 2014). These effects could also justify 75% of the changes in the follow-up phase. This study revealed that integrated group therapy reduced anger and guilt in bereaved individuals with PGD arising from the corona-caused death of loved ones. This outcome may be due to employing different techniques, such as writing letters to decedents, cognitive restructuring, and the empty chair of Gestalt therapy (Gupta, 2018).

These techniques make individuals recognize and express their hidden and suppressed anger toward the decedent or themselves. Furthermore, using the empty chair, writing a letter to the decedent, and expressing unsaid words and regrets to the decedent decrease anger and increase grief acceptance in bereaved people (Tsvieli & Diamond, 2018).

Employing cognitive restructuring techniques and identifying and challenging cognitive distortions and inefficient basic beliefs can reduce the feeling of guilt resulting from inefficient thoughts (Meichsner et al., 2020). The impact of our intervention on the withdrawal of self and other blames may be rooted in the decline of negative cognitions and avoidance behaviors and can help individuals solve their family problems (de Groot et al., 2007). As observed in the study Arslan et al. conducted on normal bereaved families, possessing opportunities to participate in groups and receiving counseling assists individuals to notice that they have made no mistakes, and their feelings of shame and guilt considerably lessen (Şimşek Arslan & Buldukoğlu, 2019). Groups create atmospheres wherein the problems related to past relationships and insecure attachments can be expressed and evaluated and provide participants with opportunities to set goals and be responsive to their progress (Larsen et al., 2021). Participating in groups and challenging the thoughts of other group members make individuals aware of their inefficient thoughts and pave the way for them to challenge and change their own thoughts (Leiderman, 2019).

In our study, we assessed three negative symptoms (depression, anger, guilt) that are associated with prolonged grief disorder. While it was concluded that integrated therapy could help reduce these variables, prolonged grief disorder is a separate construct, and the effects of this integrated therapy on this construct were not directly measured (Rosner et al., 2011). This issue should be considered when reviewing the results of our study. Furthermore, there have been several different grief treatment protocols that have utilized both elements of CBT and Gestalt therapy. These treatment protocols have shown to be effective for treatment of prolonged grief disorder and so these probably be also effective for PGD arising from COVID loss.

Compared to past studies, the merits of this design include (1) Selecting the subjects with the help of skillful psychologists and psychiatrists, (2) Assigning the subjects into groups randomly, which could enormously prevent testing errors, (3) Dividing the participants into experimental and control groups to separate the effects of the intervention from spontaneous changes in the subjects and present more reliable results; and (4). Considering a follow-up phase besides the pretest and posttest to ensure the impacts of the intervention even 2 months after the experiment.

Some of the limitations of this research were a 2-month interval for administering the follow-up test and the fewness of subjects. It is suggested that future studies use larger samples and more extended follow-up periods.

Maybe the most significant limitation of our study was the use of depression, anger, and guilt inventories because of the lack of availability of better native-translated and validated questionnaires. These measurements only evaluate some aspects of the grief process and do not assess prolonged grief disorder as a construct as a whole. Also, these inventories only measure negative variables for the effects of integrated therapy. The use of only negative variables might introduce pathology-focused bias, which is somewhat in opposition to the spirit of the dual process of coping with bereavement models and the Gestalt therapy method. We recommend that future studies use more comprehensive and positive measurement methods like Personal Growth Initiative Scale or Prolonged Grief Disorder (PG-13) questionnaire.

Furthermore, the RCT design of our study might introduce its limitations. While using a randomized clinical trial design could eliminate the selection bias and decrease the effects of confounding factors, the generalizability of the results might be more limited than varied study designs. Moreover, finally, because the control group patients were treated after the study’s conclusion, no long-term assessment of the effects of integrated therapy on the PGD of the subjects included in our study could be performed.

Conclusion

This study provided evidence that integrated group therapy could help with some of the symptoms of PGD resulting from the corona-caused loss of loved ones. The increasing rise of the disease statistics, besides its resultant death toll, has caused many people to experience prolonged grief derived from the coronavirus. Owing to the sudden and unexpected death of loved ones and the impossibility of mourning and grieving because of long-term quarantines, these individuals remain in the grief cycle and experience different feelings, such as grief, sorrow, helplessness, anger, anxiety, confusion, nervousness, and guilt. Hence, by applying several techniques, such as employing cognitive restructuring, deep abdominal breathing and relaxation, the empty chair, writing a letter to the decedent, and perceiving and identifying different emotions and physical states of the person, integrated group therapy can assist with accepting the death of a loved one. Moreover, groups are sources of inspiration and exemplification and increase inter-group intimacy and relationships that can overstep group boundaries. Recognizing appropriate coping strategies to manage challenging situations by applying the cognitive-behavioral and mentioned techniques can help decrease some of the depression, anger, and guilt in bereaved individuals with corona-caused PGD symptoms.

Still, further studies using integrated therapy with more encompassing inventories are needed to understand how these treatments could help patients with PGD arising from COVID.

Author Biographies

Jamshid Jarareh, Ph.D. is an assistant professor of psychological counseling at the Humanities School of Shahid Rajaee University. He is the director of the psychological clinic of Shahid Rajaee university and his research includes the studies on effects of group therapy on anxiety and anger, different methods patients use for coping with trauma, and the treatment of patients with PTSD.

Kosar Bardideh is a doctorate student of psychological counseling at the psychology and counseling school of Azad University. Her research focuses on cognitive behavioral therapy, Mindfulness-Based Cognitive Therapy, and group therapy for the treatment of anxiety-related disorders like nocturnal enuresis, PTSD, and grief-related disorders.

Fatemeh Bardideh is a doctorate student of psychological counseling at the psychology and counseling school of Azad University. Her research focuses on group CBT, existential therapy, and its effects on personal anxiety disorders and adult grief.

Majid Monfared is a master’s student of psychology and biostatistics at Khayam University. His research interests include panic disorders and the use of mixed-design models for evaluating psychological treatments.

ORCID iD

Kosar Bardideh https://orcid.org/0000-0002-8107-9894