Journal of Chemotherapy and Cancer Research

Narrative Therapy in Complicated Grief: A Systematic Literature Review

Petra Santos and Luisa Soares*

Narrative Therapy in Complicated Grief: A Systematic Literature Review

Petra Santos¹ and Luisa Soares^1*

¹Faculty of Arts and Humanities, Department of Psychology, University of Madeira, Portugal, orcid: 0009-0005-8258-5931
²Faculty of Arts and Humanities, Department of Psychology, University of Madeira, Portugal, orcid: 0000-0002-5373-1320

*Corresponding author
Luisa Soares, Faculty of Arts and Humanities, Department of Psychology, University of Madeira, Portugal.

ABSTRACT
The present article focuses on a tertiary intervention based on a systematic literature review guided by PRISMA which explores the contributions of narrative therapy and Constructivist-narrative strategies in the transformation of the process from complicated mourning to normal mourning [1]. It is intended to target the scientific community and mental health professionals in providing care to individuals facing complicated grief. We hope to advance scientific knowledge and provide an empirical basis for future studies and the development of more effective constructivist-narrative clinical interventions. We analyzed 21 studies in order to present the most current narrative and constructivist-narrative interventions (last five years: 2019-2023), fulfilling the predefined objectives. The results are organized into three categories of analysis: (i) cognitive-narrative therapy; (ii) constructivist-narrative strategies, including meaning reconstruction approaches, group therapies and integrative treatments; (iii) therapeutic writing. It includes current studies that investigate the effectiveness of narrative therapy in complicated mourning, and we observed that constructivist-narrative strategies appear to be flexible and effective, capable of adapting to the specific needs of individuals in mourning, regardless of the circumstance, type of loss and relationship as deceased.

Keywords: Complicated Mourning, Narrative Therapy, Effectiveness of Psychological Intervention

Introduction
Mourning is a natural and inevitable process, but it can be transformed into a significant emotional challenge when it evolves into complicated grief with intense and disabling suffering [2]. The reconstruction of two existing psychological treatments to address complicated mourning is crucial to carry out a multidimensional intervention, adapted and specific to the loss of a loved one [3-5]. Waller et al. indicate that psychological interventions in the mourning process can be classified on three levels: primary, secondary and tertiary. The literature demonstrates little effectiveness in primary interventions, showing better results in secondary and tertiary interventions, or perhaps for risk groups and individuals with symptoms of complicated grief [6].

The present article focuses on a tertiary intervention based on a systematic literature review guided by PRISMA, which explores the contributions of narrative therapy and Constructivist-narrative strategies in the transformation of the process from complicated mourning to normal mourning [1].

Narrative therapy and a constructivist perspective offer a broad view of the complexity of mourning and two potential paths to reconstruction and resignation. Narrative therapy stands out for centralizing individual narratives in the reintegration process, which is essential for the difficulties of adaptation, manifestations of painful emotions, construction of meaning and reconstruction of identity after significant loss [7].

This study begins with a theoretical framework about the subject, exposes the methodology and presents the main and most recent results originating from the systematic review of the literature, aiming to understand the need to understand the best clinical practices to deal with the challenging process of complicated mourning.

This article assumes a constructive and critical position between theory and practice, attempting to fill the lack of scientific knowledge on the topic. As such, it provides a detailed and well-founded investigation into the effectiveness of narrative therapy in addressing complicated mourning. It is intended to target the scientific community and mental health professionals in providing care to individuals facing complicated grief. We hope to advance scientific knowledge and provide an empirical basis for future studies and the development of more effective constructivist-narrative clinical interventions.

The Complicated Grief 
The death of a loved one is a universal and inevitable event, predisposing the mourning process, which is rich in memories and emotions. This process can be painful in emotional, social, behavioral, cognitive and physiological dimensions [5,7-9].

When the mourning process is prolonged in frequency, severity and chronicity, the emotions and feelings remain persistently intense and afflictive, resulting in complications of normal mourning [2,9,10].

The literature encompasses various terms to refer to the non-integrative, complicated and prolonged mourning process, namely chronic mourning, prolonged mourning, complicated mourning, goodbye mourning, pathological mourning, unresolved mourning, abnormal mourning, dysfunctional mourning and traumatic mourning [9,11]. This investigation will use the term ‘complicated mourning’ to refer to the disturbance of mourning, due to its greater prevalence and association in literature [12-14].

Diagnosis and Classification of Complicated Grief Disturbance
Perspectives of DSM-V and CID-11
The Diagnostic and Statistical Manual of Mental Disturbances-V (DSM-V) initially defined this non-normative process of mourning as a persistent complex mourning disturbance. This disturbance presents criteria that include the experience of the death of a loved one and the presence of cognitive, emotional and behavioral symptoms such as persistent sadness of the deceased, intense emotional pain, worry about the loved one and the circumstances of the death, difficulties with the oil of the death, emotional numbness, difficulties in positively expressing a loved one, anger, maladaptive evaluations and avoidance of excess emotions. Aspects of social disturbance and/or identity are also observed: the desire to die and reunite with the deceased, difficulties in trusting, solidarity, absence of meaning in life, reduced sense of identity, lack of interpersonal interest and carrying out activities and future plans. These symptoms should persist for at least 12 months after loss in adults, and six months in children, this being the time interval necessary to differentiate normal mourning from disturbance from persistent complex mourning.

The International Classification of Doenças-11 (CID-11) identifies the complicated mourning process as a prolonged mourning disturbance, with criteria parallel to the DSM-V [15]. It adds criteria related to persistent and generalized desire and anxiety for a loved one, guilt and self-censorship, denial and confusion [10,16,17]. According to CID-11, prolonged mourning disturbance is present six months after the loss [10,16,17].

In an attempt to harmonize persistent complex mourning disturbance with prolonged mourning disturbance, a group of researchers met in June 2019 [11]. It concluded that the DSM-V journal version integrates the disturbance. Of prolonged mourning, this diagnosis was approved in November 2020 [11,18,19]. The diagnostic criteria remain corresponding to previous versions [10,11,16,19].

The constructivist perspective of grief 
From a constructivist perspective, mourning is an individual, fluid and dynamic process of active construction of meanings and identity in response to the loss of a loved one. It implies a reconfiguration of two pre-existing meanings of individuals in mourning, affecting their functioning, values, identity, interpersonal and spiritual dimensions [20,21]. The full contribution of constructivism to the study of mourning is centered on narrative, which refers to the life stories of individuals and their interpretations and retellings. It is defined as a neurological, psychological and social process whose events are elaborated and organized around a specific theme and meaning [4].

The death of a loved one challenges the identity of the individual, turning the experience of mourning into an emotional transition that is difficult to integrate into reality, revoking the assumptions that guide their life history [4]. In the context of mourning, narratives are crucial to integrate loss, considering the personal, cultural and spiritual particularities that shape identity. A maladaptive integration can result in disorganization in the death narrative, triggering a prolonged process of searching for meaning and purpose, a reality marked by the absence of the deceased, manifesting complicated mourning [4].

To cope with mourning safely, individuals must attribute meaning to death, understand its causes, find hope, benefits and learning in the experience, and reorganize their identity in accordance with a new reality [22].

Contributions of Narrative Therapy to the Complicated Grief Process
The complicated mourning process is emotionally challenging and causes intense suffering, requiring multidimensional psychological interventions specific and adapted to the loss [3,4,5].

Narrative therapy, influenced by constructivism and social constructionism, emerged in the 1980s as one of the most prevalent contemporary psychotherapies [23,24]. Our pioneers are Michael White and David Epston, who were inspired by the ideas of Gregory Bateson, Jerome Bruner and Michel Foucault [25]. It is an extension of cognitive-behavioral therapy, concentrated on the narrative process, which aims to increase coerência, complexity and multiplicity of the client’s discursive construction, promoting development, freedom and creativity.

Narrative therapy is relevant to complicated mourning, especially to the difficulties of adaptation to loss and the manifestation of negative emotions, often related to the resistance of the individual in mourning to reconstructing a new reality after the loss of a loved one [7]. Complicated mourning, linked to loss of identity, finds narrative therapy a reparative path, with the objective of deconstructing the dominant narrative and collaborating in the co-authorship of a coherent narrative, formulating new possibilities for the self [26].

Individuals with complicated grief frequently express problematic narratives that distort temporal perception and are centered on intense suffering. These narratives reflect an irrecoverable past and the difficulty of envisioning a meaningful future, leading to the absence of meaning in life [27]. Narrative therapy can transform these narratives, discovering unique results, following the phases of deconstruction (separation of lost identity), reconstruction (co-creation of adaptive narratives) and consolidation (internalization and integration of new narratives in identity, promoting meaning and purpose, [25,28].

Neimeyer observed that it is common for individuals in mourning to centralize the deceased in their lives, mixing positive messages and difficulties in moving forward [21]. Narrative therapy helps manage these emotions and promotes healthy adaptations. A key objective is to redefine the relationship with the deceased, as a symbolic presence in a new narrative [9,21]. Consequently, the mourning individual experiences emotional relief adapts to a new reality and builds an identity consistent with a reconstructed narrative, which is planned for the future and opens the way for new parents, habits and relationships [3]. Another objective is the creation of metaphors that confirm lost meaning, emphasizing difficult aspects for the individual in mourning [29].

Narrative therapy is not complicated mourning and the attribution of meaning, which is fundamental for the grieving individual to face loss and reconstruct their reality [7]. Narrative therapy organizes and restructures the experience of death, allowing the grieving individual to remember the loss in a safe and symbolic way, express feelings and keep the memory of the deceased alive in a meaningful way [30].

Constructivist Strategies-Innovative Narratives Not Complicated Mourning
Neimeyer highlights the importance of metaphorical, poetic and narrative strategies, which also provide direct verbalization, especially in cases of complicated mourning [21]. Ricks et al. highlight creative narrative strategies such as photography, films, works of art, writing and music [31]. These tools favor the expression and reconstruction of narrative, contributing to creating new perspectives for the problems faced by individuals in mourning.

Expression of Art
In expressive arts, different forms of therapy are used [31]:

Phototherapy: Clients use photography to reveal the world from their perspective, expressing feelings, memories and experiences through captured images. Phototherapy allows self-exploration and self-direction and helps to understand emotions and figurative contexts.

Films: Promising tools to discuss feelings, exhibitions and personal experiences. The clients assume the role of directors, reconstructing and retelling their life narratives through the analysis of the stories represented by actors, or they become directors of the film.

Music: In narrative therapy, music can be used to express difficult emotions, with lyrics that symbolize stories, promoting open and exploratory conversations.

Therapeutic Writing
Writing is an effective therapeutic intervention in health and wellbeing to help with psychological distress and promote positive effects [32]. Studies over two years have demonstrated benefits in reducing symptoms of anxiety and depression, in addition to promoting physical and mental health and increasing awareness of two personal and relational meanings. These benefits are only observed in the painful and painful aspects of life [33-36].

Second to literature, therapeutic writing in narrative therapy produces positive results in individuals with problematic narratives, due to its ability to reconstruct alternative narratives, focus on unique results, explore interpersonal factors and be culturally applicable [26]. It is a crucial reflective strategy that offers therapeutic effects and a personal experience free of external criticism and judgment. It can be used in isolation or as a complement to therapy, addressing individual variables such as cognition and emotion [37].

Non-mourning therapeutic writing included farewell letters, reflections on one’s own identity, perspectives on significant others, moments shared with the deceased, and reflections on the life story [8,38]. It facilitates the organization and integration of traumatic experiences, promoting changes in the coerência of history [37]. Discussing traumatic events helps clients identify and cope with their emotions, leading to greater emotional control and the ability to cope with painful experiences [39]. Lima and Fortim highlight the importance of written practice in preserving the memory of the deceased [30]. Paiva and Rasera and Ricks et al. also highlight that writing increases clients’ awareness of their distressing experiences, offering a deeper internal understanding [31,40]. Larsen emphasizes that it allows individuals in mourning self-revelation, resolution of pending quests, continuous creation of happy bonds and memories, and appropriation of a coherent narrative [41].

Other Therapeutic Strategies Ideas for the Treatment of Complicated Grief
A narrative retelling allows the individual in mourning to repeatedly recount the history of the death of a loved one, focusing on the characters, relationships, emotional crises and beliefs [38]. The therapist plays a decisive role in facilitating the client’s emotional expression and reflection on the meaning of the loss. This strategy, whether orally or in writing, is particularly useful in traumatic deaths such as suicide, homicide or accidents [38]. Implemented progressively throughout the treatment, it aims to reduce anguish, promote the extinction of avoidance mechanisms and explore meanings, contributing to the development of resilience and the integration of the experience of death [8,9,38].

Imaginary conversations are flexible and crucial therapeutic strategies for the assimilation and integration of the narrative of loss, especially by concentrating on the interpersonal dimension. In other words, it allows the individual in mourning to access and transform the history of death, emphasizing, above all, not the relationship with the deceased [38].

The integration of narrative therapy with metaphors facilitates the expression of stories about the death of a loved one because it represents significant symbolic experiences of a specific experience or culture [42].

In the therapeutic approach to complicated grief, it is essential to separate the loss from the client’s identity. The therapist can invite the client to attribute a name to the mourning process, facilitating that distinction. Externalization is useful for exploring the impact of grief in different areas of the client’s life and identifying external coping resources, promoting a more flexible and compassionate view of the death experience. Regarding remembering strategies, White defends its applicability in mourning, directing attention to the neglected aspects of life, apart from the loss that dominates the narrative [26].

Methodology
This study is a qualitative descriptive approach and uses data and conclusions from a systematic literature review, carried out on the contributions of narrative therapy and constructivist-narrative strategies in the complicated mourning process. A systematic review of the literature follows the PRISMA guidelines [1].

The research objectives are (i) to investigate the effectiveness of narrative therapy in complicated grief, (ii) to explore how constructivist-narrative strategies help individuals in mourning to integrate their loss safely, and (iii) to understand the benefits. It gives therapeutic writing in the continuity and reconstruction of the life of two individuals in complicated mourning.

The article was conducted based on the following research quests:

1. What are the contributions of narrative therapy in complicated mourning?
2. What are the benefits of constructivist-narrative strategies in complicated mourning?
3. What are the benefits of written therapeutics in complicated grief?

Research Strategies
A systematic literature search was carried out based on the main keywords related to narrative therapy and complicated grief, using Boolean operators OR and AND to guarantee an inclusive and precise approach.

These include the terms “Narrative Therapy,” “Narrative Clinical Psychology,” “Therapeutic Writing,” “Narrative Change,” and “Narrative Reconstruction” to open a variety of therapeutic interventions and strategies based on narrative. The terms “Prolonged Mourning Disturbance,” “Long Mourning,” and “Complicated Mourning” are added to ensure the relevance of the two studies selected for the topic under analysis.

The databases used are Google Scholar, B-On, PubMed, Springer Link, Taylor and Francis, Web of Science and Science Direct. The research was carried out predominantly in English, with the exception of the Google Scholar database, which was also carried out in Portuguese due to the greater probability of providing master’s and doctoral dissertations. 

Selection Criteria
The inclusion criteria: (a) period of 23 years (2000-2023); (b) global research studies; (c) studies in Portuguese and English; (d) masters and doctoral dissertations; (e) Scientific, review and systematic literature review articles; (f) studies with narrative therapy as an intervention for complicated grief; (g) studies with therapeutic writing as an intervention strategy for complicated grief; (h) studies with constructivist-narrative strategies such as intervention for complicated mourning; (i) studies that show the presence of complicated mourning; (j) open access studies.

Selection of Studies
The selection of two studies for a systematic review of the literature took place between September 2023 and January 2024 (are still ongoing). The PRISMA 2020 flowchart (figure 1) illustrates the review process, which included the identification of duplicate articles, the selection of titles and/or abstracts, the verification of the complete text and the comprehensive reading of the studies.

Results
The results of the phases of the systematic review of the literature carried out are represented in the PRISMA flowchart (figure 1). The present article analyzed 21 research studies in order to present the most current narrative and constructivist-narrative interventions (last five years: 2019-2023), fulfilling the predefined objectives.

The results are organized into three categories of analysis: (i) cognitive-narrative therapy; (ii) constructivist-narrative strategies, including meaning reconstruction approaches, group therapies and integrative treatments; (iii) therapeutic writing. It is noteworthy that, since this investigation uses the term ‘complicated mourning’, in the presentation of the results, the specific terms of each study will be used to ensure precision and respect for the definitions and contexts originating from the authors.

Cognitive-Narrative Therapy for Complicated Grief
Marques investigated the effectiveness of a Cognitive-Narrative Therapy Program with four patients from diverse groups (child, spouse, mother and father) [43]. The intervention, composed of six sessions, included strategies for the reconstruction of meaning, such as recounting the history of loss and the relationship with the deceased, expressive arts, imaginary conversations and writing therapeutic letters. Writing was used to construct meaning and understand identity after it was lost. Imaginary conversations involve the recovery of emotional connection, happy memories and resolution of pending issues. The author achieved non-significant results, with symptoms of prolonged mourning remaining in the patient, and our found symptomatic meliorations in emotional pain, confusion and shock.

The study by Marques implies a careful analysis of the effectiveness of cognitive-narrative therapy [43]. In the absence of significant advantages, there is a need to personalize therapy to meet the specific needs of each patient.

Constructivist Strategies-Narratives not Complicated Mourning

Construtivist Approaches-Narratives of Reconstruction of Meaning
Braga et al. will carry out a study in order to analyze the Constructivist Approach to the Reconstruction of Meaning in five clients with prolonged mourning from the previous study by Alves et al. [44,45]. It is an intervention composed of 15 individual and weekly sessions. It uses constructivist-narrative strategies such as narrative reportage, imaginary conversations and correspondence with the loved one, aiming to provide clients with a new understanding and healthy meaning to their losses before reconstructing meanings. This approach does not have a specific or manualized structure [44]. Three clients reported clinically significant reductions post-treatment. The strategies used will allow a continuous bond as a loved entity and new adaptive ways of integrating loss with new meanings, constructing new narratives [44].

The studies by Lichtenthal et al. and Pelacho-Rios and Bernabe-Valero validate the effectiveness of Centered Grief Therapy in a country with complicated mourning [46,47]. It consists of an integrative and existential intervention, combining logotherapy, narrative therapy and cognitive-behavioral therapy, over 16 weekly sessions lasting 60 to 90 minutes. It Includes psychoeducation, experiential exercises and structured discussions focusing on topics associated with meaning, identity, purpose and legacy.

Lichtenthal et al. intended to help the countries learn how to coexist with their loved ones through the creation of a coherent narrative, which incorporates the deep meaning of the life of their children in their life narratives, facilitating the preservation of the continuous link [46]. The countries present positive feedback on the intervention, including long-term benefits following the intervention in the disturbance of prolonged mourning, sense of meaning, depression, despair, continuous bonds, posttraumatic growth, positive affect and various domains of health-related quality of life. Most of the treatment options are reduced or increased in the three-month support period [46]. On the other hand, a systematic review by Pelacho-Rios and Bernabe-Valero concluded that despite these interventions being useful in dealing with parental mourning, depression and despair, the results are not borderline enough to be considered significant [47].

Rafaely and Goldberg developed an intervention method called Grief Snow Globe to help individuals in grief in the externalization of emotions and in the restoration of experiences of mourning and loss through narrative therapy [48]. The intervention aims to restructure the loss, explore new perspectives on mourning, facilitate the identification of meaning and promote a continuous connection with the deceased through new meanings. The case study presented involved a young man who lost or fell in love, whose externalization and personification of two of her feelings were worked on, encouraging her to share her story without joy. The results indicate significant benefits for the client, including the creative process of mourning, the discovery of purpose and hope in the future, and the ability to establish new relationships [48].

Group Therapies for Complicated Grief
Lacasta and Cruzado and Supiano et al. address a Group Therapy for Complicated Grief, composed of motivational interview procedures, cognitive-behavioral therapy, prolonged exposure and constructivist-narrative activities associated with the reconstruction of meaning: a retelling of the history of death, imaginative conversations with the deceased and sharing of photographs and memories, to integrate memories [49,50]. Many strategies are only applied in more than one session, a total of 16 weekly sessions.

In the study by Lacasta and Cruzado, the authors intend to compare the effectiveness of group therapy with a psychoeducational intervention and emotional expression in 249 participants randomly distributed under two conditions [49]. The participants in group therapy present significant joys, identifying the normal symptoms of complicated mourning without accompanying them for six months. This therapy has been shown to be effective, maintaining the effects without accompaniment of 12 months, being characterized as low cost and accessible to a large number of individuals. In fact, it was efficient in reducing depression, anxiety and despair, being superior to psychoeducational intervention [49].

Supiano et al. indicate that throughout the intervention, there are significant benefits in complicated mourning, in interpersonal needs, in reducing symptoms of anxiety and depression, and in restoring functions, providing useful tools for integrated mourning [50].

Baumann et al. will carry out a study with 168 more people in mourning and 155 countries in mourning, to evaluate the psychological symptoms of prolonged mourning disturbance, major depressive disturbance or posttraumatic stress disturbance through the 4-week Family-Oriented Intervention Programme [51]. Rehabilitation (FOR). This program includes group therapy and complementary individual sessions, with cognitive-behavioral and constructivist-narrative components such as exposition, psychoeducation, cognitive restructuring, perspective taking, future planning, emotional regulation, narrative retelling, use of photographs to share stories, reading or sharing stories, music or texts. The results show significant reductions in symptoms of prolonged mourning disturbance, major depressive disturbance, and posttraumatic stress disturbance. There is also a significant blessing in the quality of life. Although some participants still present severe symptoms at the end of the treatment, the evaluation of the intervention program provides promising preliminary results regarding its effectiveness [51].

Integrative Treatments for Complicated Grief
Narrative Reconstruction Therapy is an intervention adapted to the disturbance of prolonged mourning based on the disturbance of posttraumatic stress. With a 16-session protocol, the objective is to reconstruct a memory narrative related to loss, integrating elements of psychoeducation, exposition, narrative construction and addressing related processes. The mechanisms of narrative change include integration with autobiographical memory, search for meaning through external, internal and reflective narratives, and emotional labeling [52,53].

Elinger et al. developed studies with the objective of presenting the effectiveness of therapy in ten patients with prolonged mourning disturbance and a woman in mourning for a suicidal child and for a husband who has lost a canker [52,53]. An intervention allows patients to identify significant and dissociated moments and feelings, integrating the memories of the deceased, as well as facilitating the creation of new connections between the lost memory and past experiences, contributing to integration [52]. In autobiographical memory [53]. The repetition of the narrative allowed the acquisition of positive elements related to the film, and the writing was useful to communicate as well. The studies show significant reductions in symptoms of prolonged mourning disturbance, depression and posttraumatic stress disturbance, as well as elevated levels of trauma integration [52,53].

González et al. illustrate a study intended to promote meaning in the narrative of a client who lost her life to suicide through the strategy of Restorative Reconnaissance and psychedelic experiences [54]. This strategy is a brief and structured intervention, composed of ten sessions, that integrates grief management skills (including relaxation training), celebration of the life of the deceased through part of positive memories and experiences, and exposure to images related to history da morte (sharing the narrative of the death and recounting the violent event). A significant clinical decrease was observed in the levels of psychopathology, including not complicated mourning. The client develops a more serene image of himself, establishes a continuous bond with himself, resolves pending issues and constructs new narratives with new meanings [54].

Studies demonstrate the effectiveness of Accelerated Resolution Therapy in the treatment of complicated mourning, posttraumatic stress disorder and depression in 54 informal caregivers  and two mature women [55,56]. It is a four-session therapy that uses image rewriting, memory reconsolidation, guided visualization with eye movements, desensitization, processing of distressing memories and exposure. It concentrates on the current experience and the history of the individual and not our symptoms, using metaphors and Gestalt principles to explore themes, relationships, unfinished quests and cognitive dissonances. Buck et al. (2020) almejaram significant results in symptoms of complicated mourning, perturbação de stress pós-traumatic e depressão, os quais foram consistentes oito weeks após o treatment. Clients of the study by Tofthagen et al. will be able to re-create the death experience, focusing on painful emotions, processing the traumatic event and reconstructing the feeling of guilt [56]. As significant changes in complicated grief and its comorbid conditions, we suggest the effectiveness of Accelerated Resolution Therapy for the treatment of complicated grief and differential psychopathologies, being an appropriate non-pharmacological treatment [55, 56].

Tur et al. studied the effect of an internet-based cognitive-behavioral program, called the GROw Program, in six adults with prolonged mourning disturbance, mostly for two country deaths [57]. The program was composed of psychoeducation, behavioral activation, mindfulness, exposure, reconstruction of meaning through a diary, cognitive reconstruction, imaginary conversations with the deceased, photographs, coping strategies and a plan of projection for the future. The goal of two participants who completed the treatment was to recover and obtain clinically significant alterations in the symptoms of mourning, mainly in the dimensions associated with persistent anxiety and loss due to the physical presence of the deceased and intense sadness [57].

Quero et al. compare the long-term effectiveness of two interventions for adaptation disturbances and complicated mourning: Traditional Treatment and Virtual Reality [58]. Both treatments will consist of six weekly sessions, with psychoeducation, narrative exposition, positive psychology strategies, constructivist-narrative strategies such as a book of life (written from a book used to reflect on the experience of loss and relationships with the deceased, creating meanings), a vital trace (seeks for specific periods of painful events) and a letter for the future (written in a letter for oneself). Both interventions showed significant improvements in the post-treatment, relatively complicated grief. Without long-term support, Virtual Reality presents a higher percentage of recoveries, ensuring significant clinical change [58].

Written Therapeutics for Complicated Grief
Thatcher investigated the Paradigma of Expressive Writing in individuals in mourning six years ago [59]. The intervention involved the completion of ten writing tasks, 20 minutes a day. The tasks address various mourning topics related to dependencies, such as vice, anxiety, anger, sadness, regret and memories. They are divided into two categories: master instructions and poetic instructions. The instructions below consist of structured writings with titles, statements and questions about specific topics. Poetic instructions involve expressive writings encouraging reflection on an emotional, cognitive, physical or social experience associated with the mourning process, including reading a related poem. Six participants reported reductions in anxiety after the writing intervention. Three participants express a deeper understanding of their mourning process, tending to review two moments of loss with less emotional shock. The writing allowed the participants to develop a greater self-awareness of their progress and acquire a new perspective on their experiences of mourning [59].

Studies validate the effectiveness of the Internet-Based Cognitive-Behavioral Program among individuals with prolonged mourning due to cancer and who face loss due to suicide [60,61]. The Cognitive-Behavioral Program, Based on the Internet, uses cognitive-behavioral strategies, available in three modules over five weeks. The first module is intended to confront the loss and the remainder for its restoration and integration. 45 minutes. Communication between therapists and individuals in grief is asynchronous, carried out only by e-mail. The main Objectives were: Significant clinical benefits in prolonged grief, depression, posttraumatic stress, posttraumatic growth and mental health [60,61].

Niemeyer et al. investigate the quality and function of the therapeutic alliance during an online treatment for suffering in mourning [54]. The treatment presents characteristics similar to the Internet-Based Cognitive-Behavioral Program. Foram demonstrated continuous joy without complicated mourning and symptoms of depression [62].

Baker-Cole’s study investigated the process of conjugal mourning in three participants through creative artistic interventions such as therapeutic writing and design integrated into post-modern and constructivist models of mourning [63]. Understanding the contributions of the tools in the treatment of grief symptoms, particularly the integration of loss, reconstruction of meaning and continuous links, was the objective. The intervention consists of several sessions of creative arts, with two main stages: (i) drawing of figures using cores and symbols to express the story of death and (ii) therapeutic writing, in which the participants will write for ten minutes about the desired results. Even the therapeutic writing in the intervention resulted in no increase and stabilization in the areas of reconstruction of meaning, containing continuous bonds, personal growth and valorization of life. The combination of therapeutic writing and writing has a positive effect in reducing the symptoms of grief and promoting the reconstruction of meaning and adaptation to loss [63].

Larsen et al. present two cases of young adults who lost both their lives and their lives respectively [64]. Letter writing was used to communicate with the deceased, express emotions and reflect on the relationship. This strategy was important to understand the ambivalence of feelings as a loved one, deal with the loss, maintain the bond and oil the emotions experienced, creating new narratives. In both cases, it will be able to manage and understand the mourning process [64].

Discussion
Complicated mourning is considered a clinical disturbance, differentiating itself from normal mourning in terms of subjective experiences, intensity, duration and commitment to the physical and mental health of the individual at a cognitive, emotional, behavioral, social and physical level [2,5,65]. It perpetuates a repetitive cycle, with serious and disabling responses to loss, with symptoms of intrusion, anxiety, and the health of the loved one is at the center of life, affecting considered populations throughout the world [19,46,66-68].

According to White and Epston, psychological suffering is related to the creation and maintenance of problematic narratives [25]. The loss of a loved one alters the sense of meaning and identity, producing a dominant narrative whose thoughts and painful emotions are placed with emphasis on a parallel temporal reality, [27,48,64]. Second, Gonçalves, narrative therapy is a treatment of social constructionism, open, creative and co-constructed, which allows understanding of the meanings implemented in problematic history [23]. Together with constructivist-narrative strategies, we address the crucial development of adaptive and integrative narratives, highlighting their richness in the autonomous construction of new realities and different meanings [48]. Narrative therapy learns the competencies and experiences of the individual in mourning, co-constructing a new identity in which the loss is externalized [48]. The process of reconstructing meaning is seen as an integral and crucial part of the integrated process of mourning, which implies the realization of the consequences, benefits and learning of experience, face-to-identity and insertion in a new reality [22,38].

The transformation of a problematic narrative into a coherent and functional narrative through the attribution of meaning, power or personal and interpersonal development of the individual in mourning and associates it with subjective wellbeing [38, 48]. This process is easy to feel and capable of experiencing sad mourning without the physical presence of the deceased [8,25]. This narrative change is achieved through three phases of narrative therapy (deconstruction, reconstruction and consolidation) [25]. It allows the discovery of two unique results or moments of innovation, given that the client has been able to think, feel and move. Differently from the father of the problematic narrative, or seja, debate the dominant father, separate his identity from the loss of the deceased, restructure his life story and achieve new meanings and purposes [28,69].

Narrative therapy strategies and creative interventions demonstrate benefits in complicated mourning, facilitating emotional expression and consequent reconstruction of the bond, not only verbally but also visually and in writing [48]. Individuals in mourning have the possibility of reflecting on the past and relationships with their loved ones, reaching a metacognitive and emotional understanding of what they are feeling, not present, and working on a future perspective with hope. An alternative narrative makes it possible to increase competencies and construct life experiences, social context, language and time of the individual in mourning, enabling him to be the protagonist of his story [23-25].

This article includes current studies that investigate the effectiveness of narrative therapy in complicated mourning and observe that constructivist-narrative strategies appear to be flexible and effective, capable of adapting to the specific needs of individuals in mourning, regardless of the circumstances—type of loss and relationship with the deceased.

According to Larsen, a large part of the mourning population does not need psychological therapeutic interventions, fulfilling the normal mourning process for integrated mourning [41]. However, the author indicates that about 40% of individuals who suffer significant loss benefit from psychosocial support. Tertiary interventions based on narrative therapy and composed of constructivist-narrative strategies show effectiveness in reducing symptoms of complicated mourning, adaptation to loss, integration of painful emotions and maintenance of a continuous bond [70]. These interventions are grouped into three categories: (i) cognitive-narrative therapy for complicated mourning, (ii) constructivist-narrative strategies for complicated mourning, and (iii) written therapeutics for complicated mourning. The selection of these categories will show in a more organized way the results that are significant and relevant to the research objectives.

Category (i) ‘cognitive-narrative therapy without complicated mourning’ was included due to its approach, which promotes the metacognitive and self-reflective capacities of the client, ensuring conditions for their creative unlocking. It refers to the construction of rich and complex alternative narratives in content, as structured with coherence and meaning. In addition, it is a therapy based on non-constructivism and non-social constructionism, which ensures the existence of co-constructive processes in multiple parameters of life experiences existing in the past, manifested in the present and idealized for the future, especially as a major objective: Mudanças do not function narratively [23].

Marques’s intervention integrated elements of narrative construction and metacognitive reflection, and despite no significant results, offered relief of two symptoms and a profound opportunity for the transformation of the meaning of personal loss and growth, with patients revisiting their experiences; we will reinterpret and symbolically reconstruct them [43]. The use of metaphors and the projection of future narratives makes possible an active reconstruction of the meaning of loss, envisaging new possibilities of understanding and functioning for the self [26].

Category (ii) was subdivided into ‘constructivist approaches-narratives of reconstruction of meaning,’ ‘group therapies, ‘ and ‘integrative treatments.’ Embora, some interventions are overlapping, or intuitively, they were distinguished according to their main focus. Primarily, foram is an intervention with an emphasis on the reconstruction of the meaning of the loss of a loved one. In group therapies and grouped formats, the studies that we mention directly address constructivist-group narratives for the treatment of the phenomenon. Finally, interventions are composed of strategies of different therapies, therefore with a present constructivist-narrative dimension, in order to maximize results.

A Constructivist Approach to Meaning Reconstruction has proven to be effective in reducing symptoms of complicated mourning in certain cases [44]. This variation in response to the treatment of the participants highlights the importance of considering the individual when applying this intervention in the treatment of complicated grief, whose type of loss, relationship with the deceased and number of deaths to face and restructure must be taken into consideration. Centered Grief Therapy does not mean the benefits of integrating various therapeutic approaches, revealing flexibility, given the possibility of adapting strategies in each case. Its accessibility in in-person sessions and by videoconference, as revealed by Lichtenthal et al., suggests adaptability and accessibility to different contexts and situations, appearing to be effective for parental mourning and other forms of complicated mourning [46]. It is important to recognize that only preliminary results and further studies are necessary to validate its effectiveness and long-term benefits.

Rafaely and Goldberg do not directly mention the reduction of two symptoms of complicated mourning but instead highlight a constructivist-narrative approach crucial to treatment [48]. Narrative Reconnaissance, metaphors, artistic expression and externalization of emotions are manifest opportunities for individuals in mourning to reconstruct meanings around their losses and protection factors that help in seeking a path of emotional adaptation and transformation.

As group therapeutic approaches for complicated grief examined, we highlight the diversity of strategies used for the treatment of the phenomenon, whose relevance to the reconstruction of meaning and To express creativity in the elaboration of the mourning process, to understand imperatives [50-52]. Recognizing the need to confront loss, re-signify the relationship with the deceased and promote the integration of memories in a safe way can also be considered constructivist approaches to meaning.

As intervenções de Reconstrução Narrativa e Reconto Restaurativo, embora conceitos semelhantes teoreticamente, apresentam diferenças no focus e stratégias [52-54]. Narrative Reconstruction Therapy focuses on the reconstruction of memory related to the loss of the deceased, integrating elements of psychoeducation, exposition and coherent narrative reconstruction; restorative Reconnaissance involves grief management skills, celebration of life and exposition. Both interventions demonstrate effectiveness in reducing the symptoms of mourning, depression and posttraumatic stress disorder. Therefore, it is possible to patent a predominant constructivist-narrative aspect in the first phase and a cognitive-behavioral emphasis in the second.

Addresses different therapeutic approaches, such as psychedelic experiences, Accelerated Resolution Therapy and Virtual Reality, also producing results positive, highlighting the relevance of the diversity of therapeutic options to serve clients. There is no single or universally effective approach to dealing with complicated grief [54-56,58].

Category (iii) was dedicated to therapeutic writing strategies, whose studies indicate how to reduce the symptoms of complicated mourning disturbance.

Next, find the main narrative and constructivist-narrative strategies common among the interventions of each category. According to Silva and Carreta, these approaches are configured in emotional reflection, promotion of insights and reconstruction of personal and relational narratives [5].

A narrative retelling and the imaginary conversations with the deceased stand out as the most prominent and effective constructivist-narrative strategies, present in most of the treatments analyzed, namely, in cognitive-narrative therapy, in the constructivist-narrative approaches to reconstruction of meaning, in group therapies e our integrative treatments [43,44,46,48,49-54,57,58].

They were configured as subliminals in the expression and reduction of the emotional and cognitive intensity of grieving individuals, allowing them to achieve an understanding, acceptance and adaptive, creative and functional integration of loss experiences [43,48]. These strategies promoted the maintenance of a continuous bond with loved ones. They facilitated the construction of new narratives with new meanings and positive memories, connecting past aspects to the present and transferring them to the future, as well as helping to carry out satisfactory daily activities, develop and plan a future with hope and engage in new interpersonal relationships [44,46,48,53,54].

The narrative retelling made it possible to transform painful memories into pleasurable ones through the repeated narration of the story of death and the relationship with the deceased. This process helped to modify feelings of guilt, shame and anger towards acceptance and integration of the loss [50,53]. To this end, several versions of the story of the loss were co-created, and the grieving individual recognized their identity beyond this experience (Moreira, 2010), fulfilling the main objective of this strategy: obtaining more complex narratives filled with meaning about the death of the loved one [7,38]. It was concluded that the symptoms of complicated grief decreased significantly, with a great reduction in the desire and persistent yearning for the deceased and a lower level of sadness and pain [57].

The narrative retelling is related to White’s remembering strategy, given the reorganization of the grieving individual’s life story, in which new characters, moments and values are admitted [26]. As the narrative is told and retold multiple times, it is expected the expression of feelings, the assimilation of the loss and the reduction of ruminative thoughts, as well as the expansion in the cognitive and emotional understanding of the grieving individual, others and the world, sustaining coherence and accommodation to the new reality, with new meanings, social roles and a restored identity [8].

The imaginary conversation was mainly limited to making a symbolic and emotional farewell to the loved one, providing a sense of continuity. It proved to be a fundamental strategy in resolving pending issues, allowing the individual to put themselves in the place of the deceased and imagine what they could hear, helping to develop self-care and admiration [50]. This strategy was crucial in achieving the primary objectives of mourning from a constructivist perspective: accepting the loss, establishing a continuous bond and finding new meanings [38].

The metaphor was a strategy based on cognitive-narrative therapy and accelerated resolution therapy [43,55,56]. Metaphors are fundamental in helping to search for meaning in life [71]. According to the results achieved, it was concluded that this strategy was a useful complement in reaching new meanings and understandings for the experience of death while providing a greater level of internal and external awareness in grieving individuals. These conclusions are in line with the article by Baldwin et al. [71]. The studies analyzed alluded to the relevance of metaphors in exploring themes, relationships, pending issues and cognitive dissonances [55,56]. It is a strategy that modifies the path of pain, regulates emotional expression and limits rumination linked to death, in addition to its creation being one of the objectives of narrative therapy, whose painful periods are symbolized and clarified [8,29,43]. Through the symbolism of the metaphor, the grieving individual also maintains the continuity of the bond with the loved one [71].

Phototherapy is a self-directed method in which the therapist is able to understand and support the feelings narrated throughout the story, as well as the importance placed on the characters and contexts [31]. Through viewing photographs, grieving individuals can verbally and visually process the story of the death, which harmonizes a sense of self-efficacy and control in the new narrative that is being co-constructed. The use of photographs manifested itself as a strategy commonly used throughout group therapies and integrative treatments [49-50,57]. It is a strategy to remember the loved one in a nostalgic, affectionate, comfortable and appreciable way. It is powerful to address and preserve memories and feelings and prolong the relationship and communication with the deceased [64].

Therapeutic writing is a tool that allows transformations in cognitive, emotional, social and biological dimensions in the life of the grieving individual, therefore, an effective coping strategy [32]. It was an imperative constructivist-narrative strategy in the interventions analyzed for complicated grief in different ways. A very common form was writing letters: establishing correspondence with the loved one, saying goodbye to them and expressing real emotions and feelings, describe the current reality, and define new life plans and goals for the future [53,57,58,60,61,64]. This form of writing facilitated the exploration of the interpersonal relationship with the deceased. As in narrative recounting and imaginary conversation strategies, it promoted the creation of an ongoing relationship, generated comfort, expressed unresolved issues, processing the loss in a healthy way, with new meanings for the new life narrative, whose focus would not be death. In this context, externalization is assumed, in which the dominant narrative is deconstructed, creating new models of understanding and identity [26,49,64,72].

In addition to farewell letters to the deceased, studies also mentioned writing letters to an imaginary friend, promoting cognitive restructuring, and a letter to oneself, being beneficial for projecting one’s own reflections and respective experiences [58,60,61].

Writing can be implemented in structured and unstructured ways cognitively and emotionally [59]. The Internet-Based Cognitive-Behavioral Program included emotional and cognitive writing tasks [60,61]. It consisted of writing from the circumstances of death, expressing fears and intrusive thoughts, letters of support and encouragement to imaginary friends and symbolic farewell letters to the deceased. In this context, externalization is revealed, in which it is established that loss is an element below identity, deconstructing the narrative saturated by the problem [25,72]. In this way, it is pertinent to elucidate that therapeutic writing is transformative of the painful and traumatic experience of loss and allows a separate view of the problem, causing lasting changes [30,40].

Writing is associated with poetry, which is important in processing and reinterpreting pleasurable emotions, sharing suppressed feelings, reconstructing feelings of guilt, creating meaning and continuous bonds with the deceased, in addition to propagating personal growth and appreciation. of life [41,56,63]. Bracegirdle alludes to poetry as a form of writing that contains the writer’s emotions, thoughts, behaviors, sensations and desires, capable of representing a more complete and quality narrative that exposes the most painful moments of life [73]. Furthermore, writing is also linked to the re-authoring strategy of narrative therapy, as it reinforces positive aspects in the grieving individual’s new narrative, in contrast to the elements initially present in the dominant story [72]. It is a strategy that encourages the client’s creativity, self-knowledge and the involvement of forgotten points, as the focus is no longer on the grieving process and is rewritten on intentions, values, learning and new characters, providing growth, integration and meaning in the grieving individual through loss [73,26].

Therapeutic writing is beneficial in the treatment of complicated grief, as it allows the individual to reread what they had written, organize emotions, modify meanings, and immortalize new reflections on the history of death, contributing to biopsychosocial wellbeing [74]. Basically, it is promising in the exploration, deconstruction and reconstruction of the relationship with the loved one (significant moments, shared memories and challenges faced together), in the identification of resources and strengths (amplification of the client’s internal and external resources, especially those that are useful in coping with the grieving process), in promoting new meanings (including new interests, roles and personal goals), self-reflection and self-knowledge, and in the search for unique results [41].

In summary, therapeutic writing promotes alternative and coherent narratives regarding the loss of a loved one, integration and acceptance in accordance with the new identity. Promotes self-revelation to the grieving individual through control in the production of memories and new narratives; exposure, given the understanding that the deceased will not respond, as it is a confrontation with reality, which after each writing reveals itself to be more organized, rational and less painful; resolving pending issues, bringing together past aspects and future perspectives, as well as facing negative feelings and memories; and focus on pleasurable aspects, which when narrated will not be forgotten [24,41].

Limitations and Future Investigations
Despite the various contributions of narrative therapy to the complicated grieving process that the present investigation provides, there are certain limitations to be highlighted.

The inclusion of studies from 2019-2023 led to the exclusion of relevant information obtained in the systematic literature review published in previous periods. It is possible to decipher that, of the 71 studies assessed in the systematic literature review, only 21 corresponded to publications in the last five years, thus indicating the need for more research on the topic of complicated grief and its treatment through a constructivist and narrative perspective. The search for articles in two languages (Portuguese and English) may have led to the exclusion of relevant studies published in other languages. Furthermore, a search key composed of more words related to the theme could have reached a greater scope of relevant articles, as, of the 634 documents identified as eligible in the last screening phase, a large part did not meet the inclusion criteria, also proving the need for more current and validated investigations. To mitigate these limitations, a study that encompasses current and past articles, as well as future systematic reviews, that includes a larger search protocol, with more search terms and in more languages, would be recommended.

Studies that implement cognitive-narrative therapy in the complicated grieving process are scarce, but it is also important to recognize its relevance in treatment, calling for future investigations that show the applicability of this constructivist therapy.

Final considerations
The effectiveness of strategies that promote the organization, reconstruction of meaning, integration and adjustment to the grieving process is highlighted through symbolic methods of telling, retelling, connecting, understanding and restructuring the relationship with the deceased, accepting the experience of death and achieving integrated mourning, formulating a new identity. Narratives are essential tools for therapeutic interventions, allowing access to clients’ subjective experiences, their relationships and metaphorically attributed meanings. These mechanisms of change allow for the benefits of loss, reduction of anguish, longing, intense emotional pain and worry, development of positive memories and greater interest in daily life, recognizing that grief, from a constructivist perspective, is an active process of reaffirmation and reorganization of identity. It was intended to present that through narrative therapy and its constituents, the focus is not on psychopathology, and the objective in a complicated grief intervention is not the separation and forgetting of the experience of loss but rather the integration and co-construction of a continuous bond with the loved one and the promotion of a feeling of belonging, in a new reality [5].

References