Journal of Substance Abuse Tre

Treating complicated grief and substance use disorders: A pilot study

Allan Zuckoff, (Ph.D.)4, Katherine Shear, (M.D.), Ellen Frank, (Ph.D.), Dennis C. Daley, (Ph.D.),

Karen Seligman, (M.Ed.), Russell Silowash, (B.A.)

Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine,

Pittsburgh, PA 15213-2393, USA

Received 13 May 2005; received in revised form 15 November 2005; accepted 8 December 2005

Abstract

Empirically supported treatments for co-occurring substance use disorders (SUDs) and grief problems are lacking, despite the salience of

grief pathology in substance abusers. Identification of a syndrome of complicated grief, distinct from bereavement-related depression and

anxiety, led to the development of a targeted treatment, but this treatment has not been tried with persons with SUDs. We recruited 16 adults

with complicated grief and substance dependence or abuse into an open pilot study of a manualized 24-session treatment, incorporating

motivational interviewing and emotion coping and communication skills into our efficacious complicated grief treatment. Completer and

intent-to-treat analyses showed significant reductions in Inventory of Complicated Grief and Beck Depression Inventory scores, with large

effect sizes. Timeline Followback percent days abstinent increased significantly in both analyses, with medium to large effect sizes, and

cravings declined significantly. Study limitations notwithstanding, complicated grief and substance use treatment appears to be a promising

intervention that merits further research. D 2006 Elsevier Inc. All rights reserved.

Keywords: Complicated grief; Substance abuse; Motivational interviewing; Exposure therapy; Emotion coping

1. Introduction

Grief has long been recognized as salient in treating

persons with substance use disorders (SUDs). Bellwood

(1975) described addressing bunresolved grief Q as a key to

successful alcoholism treatment, and Blankfield (1982/1983)

found intense grief or significant bereavement in 20%

of consecutive inpatient admissions to a substance abuse

treatment center. Yet, despite numerous published clinical

accounts of grief treatment in those who abuse or are

dependent on substances, no controlled study in which

grief-specific symptoms were defined or in which both

0740-5472/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2005.12.001

Portions of this work were presented at the 158th Annual Meeting of the

American Psychiatric Association, Atlanta, GA, May 26, 2005; at the 67th

Annual Scientific Meeting of the College on Problems of Drug Depend-

ence, Orlando, FL, June 21, 2005; and at the 11th International Conference

on Treatment of Addictive Behavior, Santa Fe, NM, February 1, 2006.

4 Corresponding author. Tel.: +1 412 246 5817; fax: +1 412 246 5810.

E-mail address: zuckoffam@upmc.edu (A. Zuckoff).

grief and substance abuse outcomes were assessed has yet

been reported.

A number of terms have been used in the literature to

designate grief that is persistent and impairing. However,

until the past decade, this work was not empirically based

and there was no reliable way to identify such a condition.

In contrast, several research groups have now identified a

grief-specific condition characterized by prominent separa-

tion distress and causing chronic and clinically significant

impairment (Horowitz, Siegel, Holen, & Bonanno, 1997;

Prigerson et al., 1999). Sufferers display persistent yearning

or longing for the deceased, loneliness, preoccupation with

thoughts of the deceased, intrusive images or memories,

avoidance behaviors, anger and bitterness, survivor guilt,

and inability to accept the death. This postloss stress

syndrome is called complicated grief.

A self-report instrument, the Inventory of Complicated

Grief (ICG; Prigerson, Maciejewski, et al., 1995), was

developed to assess grief-specific symptoms; a score ofk25

identifies the syndrome when the instrument is administered

atment 30 (2006) 205–211

A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211206

z6 months after a death. Factor analysis showed the ICG to

measure a single underlying construct. The measure

demonstrated excellent internal consistency (a = .94) and

high 6-month retest reliability (r = .80). It showed good

convergence (all r = .70–.87) with other measures designed

to assess grief-related distress while also differentiating

complicated grievers from normal grievers based on

negative health consequences of bereavement.

Several investigators have replicated the finding that com-

plicated grief symptoms can be distinguished from depres-

sion and anxiety symptomatology (Boelen & van den Bout,

2005; Boelen, van den Bout, & de Keisjer, 2003;

Ogrodniczuk et al., 2003; Prigerson et al., 1996; Prigerson,

Frank, et al., 1995). Complicated grief is a postloss stress

syndrome that bears some resemblance to posttraumatic

stress disorder (PTSD). However, traumatic stress results

from exposure to a life-threatening event, whereas compli-

cated grief results from the loss of a life-sustaining person.

As a result, sadness and loneliness are prominent in

complicated grief, whereas fear and arousal are more

pronounced in PTSD. Furthermore, symptoms of longing

and yearning, as well as pleasurable reveries, are character-

istic of complicated grief and clearly distinct from traumatic

stress symptoms.

Studies have shown moderate rates of comorbidity

among complicated grief, major depressive disorder

(MDD), and PTSD—similar to rates of comorbidity for

Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition (DSM-IV; American Psychiatric Association

[APA], 1994) mood and anxiety disorders (Melhem et al.,

2001, 2004; Silverman et al., 2000). In studies that

controlled for the presence of both MDD and PTSD,

complicated grief was associated with greater mental health

and psychosocial impairments (Ott, 2003; Prigerson et al.,

1997, 2000; Silverman et al., 2000), higher risk of

suicidality (Latham & Prigerson, 2004), and physical health

problems in the aftermath of a loss (Chen et al., 1999). A

summary of the evidence for the specificity of complicated

grief can be found in the work of Lichtenthal, Cruess, and

Prigerson (2004).

Emergent evidence suggests a link between intense grief

and worsening of substance use (Prigerson et al., 1997).

Parents who lost a child were found to be at significantly

higher risk for hospitalization for substance abuse than

parents who had not lost a child (Li, Laurson, Precht, Olsen,

& Mortensen, 2005); the effect was especially strong on

bereaved mothers, whose relative risk of hospitalization was

more than double that of mothers who were not bereaved. In

a survey study (Shear, Zuckoff, et al., 2005), we found a

high rate of complicated grief among patients in a

methadone maintenance program.

Psychiatric severity, generally (Kranzler, Del Boca, &

Rounsaville, 1996; McLellan, Luborsky, Woody, O’Brien,

& Druley, 1983), and co-occurring mood or anxiety

disorder, specifically (Charney, Paraherokis, Negrete, &

Gill, 1998; Dodge, Sindelar, & Sinha, 2005; Hasin et al.,

2002; Ouimette, Brown, & Najavits, 1998), are associated

with poor SUD treatment outcomes. Treatment of

co-occurring PTSD has been shown to be a positive

predictor of 5-year substance use remission rates (Ouimette,

Moos, & Finney, 2003), and successful treatment of

depression diminishes the quantity of substance use (Nunes

& Levin, 2004). Persons with SUDs who have co-occurring

complicated grief would likewise seem likely to benefit

from effective treatment of the syndrome.

We developed and pilot tested (Shear, Frank, et al., 2001)

a novel complicated grief treatment (CGT). Results of a

randomized controlled trial of 16 sessions of CGT showed

this treatment to be superior to a 16-session standard psycho-

therapy control (Shear, Frank, Houck, & Reynolds, 2005).

However, persons with SUDs have been excluded from

these studies, in the belief that special adaptations would be

required to make treating them safe and feasible. We

therefore undertook a treatment development project to

adapt CGT for persons who abuse or are dependent on

substances. The results of an open prospective pilot study

are reported here.

2. Materials and methods

2.1. Participants

Sixteen adults (nine women and seven men) who

were ineligible for our randomized controlled trial due to a

co-occurring SUD participated in this study. Eligi-

ble participants were z6 months postloss, scored z30 on

the ICG (the higher cutoff was used to ensure caseness), and

met DSM-IV (APA, 1994) criteria for substance dependence

or abuse during the past 6 months. Exclusion criteria

included psychosis, mania, uncontrolled medical illness,

and active suicidality requiring hospitalization. The study

was approved by the University of Pittsburgh Institutional

Review Board, and written informed consent was obtained

from all participants before study procedures were initiated.

2.2. Measures

Participants were assessed by independent evaluators.

Diagnoses of Axis I disorders were made at baseline with

the Structured Clinical Interview for DSM-IV (First, Spitzer,

Gibbon, & Williams, 1996). The ICG was given at baseline,

weekly during treatment, and posttreatment to assess grief

symptoms. The Beck Depression Inventory (BDI; Beck,

1978) was given at treatment sessions to measure symp-

toms of depression. The Timeline Followback (TLFB;

Sobell & Sobell, 1996), a semistructured interview with

very good psychometric properties for quantifying both

alcohol and drug use (Fals-Stewart, O’Farrell, Freitas,

McFarlin, & Rutigliano, 2000), was conducted at baseline

to establish lifetime and 90-day substance use frequency

and at treatment sessions to record in-treatment days of

A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211 207

use. Cravings were assessed at each treatment session

via three self-report Likert-scale questions rated 0–4,

querying how often, how intensely, and how long partic-

ipants wanted to use a substance during the previous week.

A breathalyzer test for alcohol was given before each

treatment session.

2.3. Procedure

2.3.1. Treatment

All participants were offered 24 individual sessions of

manual-guided treatment for complicated grief and sub-

stance use treatment (CGSUT), delivered over approxi-

mately 6 months. All treatments were conducted by the first

author (who has a PhD in clinical psychology and has more

than 10 years of experience in the treatment of patients with

co-occurring disorders) in our university-based clinic and in

a community clinic attended primarily by low-income

African-American patients.Persons with SUDs who suffer from co-occurring emo-

tionally activating conditions are especially challenged in

maintaining stable abstinence from substances. Our goal in

adapting CGT for this population was to help patients achieve

sufficient initial improvement in substance use behavior so

that they could learn skills for managing intense emotions and

safely engage in targeted strategies for reducing grief

symptomatology. Long-term relief of grief-related emotional

activation, in turn, was expected to increase the likelihood

that patients sustain improvement in their SUDs.

CGSUT thus combines components targeting achieve-

ment of abstinence from substances and enhanced tolerance

for emotional activation without relapse (motivational

interviewing [MI] and emotion coping and communication

skills), with a proven approach to treatment of complicated

grief (Shear, Frank, et al., 2005). MI (Miller & Rollnick,

2002), designed to elicit and strengthen commitment to

change substance use behavior, was selected for its efficacy

as a brief intervention for SUDs (Burke, Arkowitz, &

Menchola, 2003; Hettema, Steele, & Miller, 2005). Three

MI sessions incorporate techniques that include a decisional

balance discussion, a values card sort exercise, and a written

change plan. Five sessions of skills building for emotion

coping and communication draw on the approaches of

emotion-focused therapy (Greenberg & Paivio, 1997)

and relationship enhancement (Accordino & Guerney,

2001). Specific strategies for enhancing recognition and

management of difficult emotions include diaphragmatic

breathing, safe-place mental imagery, and feelings recording

exercises. Strategies for improving communication include

skills for listening to and understanding others and for

effectively expressing feelings, perceptions, and wishes

to others.

As in its standard form, CGT is conducted over 16

sessions, including the introductory, active grief treatment,

and termination phases. A detailed description of CGT can

be found in the work of Harkness, Shear, Frank, and

Silberman (2002), Shear, Frank, et al. (2001), Shear, Frank,

et al. (2005), Shear, Zuckoff, and Frank (2001), and Shear,

Zuckoff, Melhem, and Gorscak (in press). Briefly, the

treatment conceptualizes complicated grief as a problem in

coping with an important loss, resulting in specific

symptoms. As this condition bears some resemblance to

both MDD and PTSD, the treatment integrates techniques

from interpersonal therapy for depression (Weissman,

Markowitz, & Klerman, 2000) and cognitive–behavioral

therapy for PTSD (Foa & Rothbaum, 1998) into a frame-

work guided by Stroebe and Schut’s (1999) dual-process

model of coping with bereavement, which posits that

adaptive coping requires attending to both loss-oriented

and restoration-oriented tasks.

Among the techniques used in this treatment is imaginal

revisiting. Similar to prolonged exposure in PTSD treat-

ment, this exercise is highly emotionally evocative. The use

of exposure techniques has repeatedly been found to be

efficacious, yet their use with persons with SUDs has been

questioned due to concerns about low tolerance for negative

affects (Pitman et al., 1991). Back, Dansky, Carroll, Foa,

and Brady (2001) and Triffleman, Carroll, and Kellogg

(1999) described procedures for safely using exposure

strategies in this population, which we adopted in a

modified form. Brady, Dansky, Back, Foa, and Carroll

(2001) conducted an open pilot study on an outpatient

treatment for PTSD and cocaine dependence, which

included use of in vivo and imaginal exposure to reduce

PTSD symptom severity, and found large effect sizes for

both substance use and PTSD outcomes.

To maximize safety, we initiated the emotionally evo-

cative revisiting exercise only with patients who showed no

increase in substance use or cravings and no suicidal ideation

after telling the therapist the story of the death. Our revisiting

procedure utilized incremental and modulated imaginal

engagement with this story, with provisions for flexibility

and clinical judgment regarding decisions to start and

continue the exposure process. Self-reported substance use

and cravings were monitored at each treatment session and

addressed as needed. Breathalyzer tests were administered at

each treatment session. Any clinically significant deterio-

ration in substance use behavior led to suspension of

evocative techniques and refocusing on substance use goals.

2.3.2. Statistical analyses

Comparisons were made to identify differences among

treatment completers and noncompleters using Mann–

Whitney U two-sided exact tests for continuous data and

Fisher exact tests for categorical data. Pretreatment and

posttreatment comparisons were made for completers and

for the entire sample on complicated grief, substance use,

and depression outcome variables using Wilcoxon signed

rank tests. A mixed model was fitted on average cravings

over time, with participants’ intercept and slope as random

effects. Effect sizes were calculated using Cohen’s d

for differences and Cohen’s h for proportions. a was set

at .05.

A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211208

3. Results

3.1. Preliminary analyses

3.1.1. Participant characteristics

Nine women and seven men signed informed consent

forms for the study and had at least one treatment session. The

mean time since the death that was the focus of treatment was

9.8 years (SD = 9.7 years, range = 0.7–31.7 years, Mdn =

7.6 years). Seven participants were grieving over violent

deaths, and nine participants were grieving over nonviolent

deaths. The mean age of the participants was 42.3 years

(SD = 9.8 years, range = 24–57 years). Eight participants

were African American, seven were Caucasian, and one was

Native American. One was married; six were never married;

and nine were widowed, separated, or divorced. Four had

lower than high school education, two were high school

graduates or equivalent, six had some postsecondary

education, and four had a postsecondary degree. Most

(n = 12) were unemployed.

SUDs at baseline included alcohol dependence (n = 3) or

abuse (n = 4), cannabis dependence (n = 3) or abuse (n = 1),

and cocaine dependence (n = 3). Three participants entered

treatment with opiate dependence and were on agonist

therapy (methadone). Participants reported use of any

substance in their lifetime a median of 24 years (1,250

weeks, range = 484–2,056 weeks). In their lifetime, all 16

participants used alcohol (Mdn = 546 weeks, range = 130–

2,056 weeks), 15 used cannabis (Mdn = 260 weeks, range =

0–1,430 weeks), 12 used cocaine (Mdn = 172 weeks, range =

0–1,496 weeks), 11 used hallucinogens (Mdn = 1 week,

range = 0–156 weeks), 9 used amphetamines (Mdn = 1

week, range = 0–364 weeks), 9 used opiates (Mdn = 1

week, range = 0–1,673 weeks), 7 used benzodiazepines

(Mdn = 1 week, range = 0–520 weeks), 5 used inhalants

(Mdn = 0 week, range = 0–6 weeks), and 4 used hypnotics

(Mdn = 0 week, range = 0–520 weeks). Excluding

prescribed methadone, during the 90 days prior to baseline,

participants used a mean of 1.6 (range = 0–3) types of

substances and used substances on 58% (SD = 36.5) of

days. During this period, one participant on methadone was

otherwise abstinent; 12 participants drank alcohol (median

drinks per drinking day = 3, range = 0–17), 9 used cannabis,

4 used cocaine, 1 used benzodiazepines, and 1 used opiates.

All participants had at least one nonsubstance use DSM-

IV Axis I diagnosis at baseline (M = 2.1, range = 1–5),

including MDD (n = 12), PTSD (n = 11), panic disorder

(n = 4), generalized anxiety disorder (n = 4), and specific

phobia (n = 1). Eleven participants were on psychotropic

medication during study participation: 10 on antidepres-

sants, 3 on benzodiazepines, 3 on neuroleptics, 2 on mood

stabilizers, and 1 on nonbenzodiazepine sleep medication.

In addition to the three participants on methadone who were

enrolled in public methadone maintenance programs, two

participants recruited from our low-income community

clinic continued to receive supportive counseling during

study participation and one participant was enrolled in a

residential program for mothers with addictions. All

participants judged grief to be their primary problem, with

the exception of their SUDs.

3.1.2. Comparison of treatment completers and

noncompleters

Eight participants (five men and three women) completed

the treatment, whereas six women and two men were

noncompleters. The mean number of sessions for non-

completers was 9.3 (SD = 5.5, range = 1–15). One

participant dropped out because of unwillingness to

continue grief-focused procedures, and three dropped out

for unknown reasons. Two participants were withdrawn for

medical reasons (abnormal electrocardiogram, gastrointesti-

nal disorder), and one was withdrawn for failure to attend

treatment sessions. One participant was withdrawn for

worsening substance use and depression after nine sessions.

This participant was one of two enrolled early in the study

whose condition worsened after telling the story of the death

during the first treatment session. The other participant was

able to restabilize and successfully complete the treatment.

Nonetheless, after these events, we changed the protocol

such that the story was not told until after the patient

completed the initial treatment phase; no further case of

worsening occurred. Two completers each had one positive

breathalyzer test; no noncompleter had positive breath-

alyzers. The two sessions in question were rescheduled, and

we ensured that the patient was seen home safely, with no

further complication.

Although higher proportions of women and those

grieving over violent deaths were noncompleters, there

was no statistically significant relationship between com-

pletion and sex (71% males vs. 37% females; h = .78,

p = .31) or type of death (67% nonviolent vs. 29% violent;

h = .78, p = .31). Among participants on antidepressants, six

completed treatment and four did not, whereas two

participants not on antidepressants completed treatment

and four did not ( p = .61). Although the difference was

not significant, completers had a lower proportion of

abstinent days at baseline (32% vs. 53%; p = .51).

3.2. Treatment outcomes

3.2.1. Symptom scores

Grief, depression, and substance use symptom outcomes

are summarized in Table 1.

Significant pretreatment-to-posttreatment reductions

were found in ICG scores in completers (M = 30.9,

SD = 15.4, S = 18, p = .01) and intent-to-treat analysis

(M = 15.3, SD = 19.7, S = 48, p = .01), with effect sizes of

2.01 and 0.78, respectively. In a comparable CGT pilot

study (Shear, Frank, et al., 2001), mean reductions in ICG

scores were 22.8 (SD = 13.14, z = �3.11, p = .002) among

Table 1

Scores on measures of grief, depression, and substance use in CGSUTa participants

ICG BDI TLFB percent days abstinent

Participant group Pretreatment Posttreatment D Initial session Final session D Pretreatment In treatment D

Completer (n = 8)

M 49.0 18.1 �30.94 26.5 11.0 �15.54 32.0 58.5 26.544

SD 9.8 14.0 15.4 12.7 10.9 5.5 26.8 33.7 29.8

Noncompleter (n = 8)b

M 46.1 46.4 0.3 27.0 26.6 �0.4 52.6 67.0 14.4

SD 9.7 8.2 6.5 10.1 13.8 7.3 43.5 31.0 55.4

Intent-to-treat (n = 16)

M 47.6 32.3 �15.34 26.8 18.8 �7.94 42.3 62.8 20.444

SD 9.5 18.3 19.7 11.1 14.5 10.0 36.5 31.6 43.4

a Manual-guided individual outpatient treatment conducted in 24 sessions over approximately 6 months.b Last observation carried forward.

4 p = .01.

44 p b .05.

A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211 209

completers and 16.9 (SD = 19.99, z = �3.51, p b .001) in

intent-to-treat analysis, with effect sizes of 2.19 and

1.45, respectively.

BDI scores showed corresponding reductions for both

completer (M = 15.5, SD = 5.5, S = 18, p = .01) and intent-

to-treat (M = 7.9, SD = 10.0, S = 40, p = .01) groups, with

effect sizes of 2.82 and 0.79, respectively. Again, this was

similar to reductions in BDI scores in the CGT pilot study for

the completer (M = 13.1, SD = 10.19, z = �2.98, p = .003)

and intent-to-treat (M = 10.4, SD = 9.93, z =�3.44, p = .001)

groups, with effect sizes of 1.80 and 1.16, respectively.

TLFB percent days abstinent from all substances

increased significantly among the completer (M = 26.5,

SD = 29.8, S = 15, p = .04) and the intent-to-treat (M = 20.4,

SD = 43.4, S = 39, p = .04) groups. Effect sizes were 0.89

and 0.47, respectively.

Among completers, mean reduction in ICG score was

30.8 for patients on antidepressants (n = 6) and 31.0 for

patients not on antidepressants (n = 2). In intent-to-treat

analysis, mean reduction in ICG score was 19.1 (SD =20.3)

for the 10 participants on antidepressants and 9.0 (SD = 18.7)

for the 6 participants not on antidepressants ( p = .31).

3.2.2. CravingsA significant negative slope was found in the mixed-

model analysis of the intent-to-treat sample, such that average

cravings decreased over time. Mean craving score was 2.2 at

treatment initiation, whereas the predicted value at treatment

completion was 1.6, F (1, 13) = 5.30, p = .04, d = 1.30.

4. Discussion

Complicated grief is a chronic and debilitating condition.

The identification of this postloss syndrome led to the de-

velopment of a targeted efficacious treatment, but the treat-

ment was previously unavailable to those with SUDs, despite

the long-recognized prominence of grief problems among

them. Our pilot study represents the first effort at establishing

the feasibility of delivering CGT in this population.

This study is limited by its small number of participants

and its open treatment design. In addition, the first author,

who was the primary developer of the adapted treatment,

administered all treatments. For these reasons, the effect

sizes we observed are likely to overestimate those we would

see in a larger randomized trial that controls for effects of

time and attention, as well as therapist effects. Nevertheless,

the results, although preliminary, are promising and suggest

that a grief-focused treatment, combined with MI and skills

building for emotion coping and communication, can

feasibly be delivered to patients with extensive substance

use histories who are actively using substances upon

treatment entry. The large effect sizes for changes in grief-

related symptoms and the concomitant improvement in

substance use and cravings support the idea that this

treatment is of potential benefit.

Clearly, it is important to be cautious when using a

treatment that is emotionally evocative in persons with

SUDs. We took several steps to address this concern. We

added a five-session coping skills component to our adapted

treatment, began revisiting exercises only with patients

judged ready for them, and monitored cravings at each

session. We were flexible in our use of evocative procedures,

allowing patients to proceed at a pace they found manage-

able. When we discovered, in two early cases, that telling the

story of the death in the first session was followed by

worsening of substance use, we changed our procedure such

that their story was not told until after coping skills had been

taught; we saw no further case of deterioration.

Only 50% of the participants completed the treatment.

Although this rate was lower than that desirable, it is similar

to that found in our pilot study on CGT that excluded

persons with SUDs. Other SUD treatment trials have

recorded high rates of dropout (e.g., completers = 28%;

Crits-Cristoph et al., 1999). In their open pilot study of an

exposure-based treatment for PTSD and cocaine dependence,

A. Zuckoff et al. / Journal of Substance Abuse Treatment 30 (2006) 205–211210

Brady et al. (2001) reported a completion rate of 39%.

Nonetheless, efforts to increase treatment retention in

CGSUT should be an important part of future develop-

ment work.

Our sample was heterogeneous where choice of sub-

stance and pretreatment severity of substance use were

concerned, and we assessed substance use outcomes solely

through the TLFB interview and weekly cravings ratings.

Concomitant psychotropic medication use was also hetero-

geneous, and several participants received psychosocial care

outside the study. Future studies would benefit from

drawing a sample from a more homogeneous population,

using a range of measures of substance use severity and

outcome (including biologic measures; i.e., urinalysis and

breathalyzer testing), and controlling for the use of

antidepressant medication and external psychosocial treat-

ment. Follow-up assessments are also needed to determine

whether gains in complicated grief symptoms are durable

and whether decreases in substance use, such as those found

in our sample, continue following treatment, especially

among those people who attained a large reduction in

complicated grief symptoms.

In summary, these findings provide support for further

research utilizing our adaptation of CGT for persons with

SUDs. Development and dissemination of an efficacious

treatment for complicated grief in persons with SUDs would

have the potential to alleviate suffering and improve

substance use treatment outcomes in those who suffer from

this condition.

Acknowledgments

This work was supported by grants from the National

Institute of Mental Health (R01 MH60783 and P30

MH30915) and the National Institute on Drug Abuse

(Administrative Supplement MH60783).

We are grateful to Krissa Caroff, B.A., Jacqueline Fury,

B.A., and Randi Taylor, Ph.D., for their assistance in the

conduct of this study.

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