Introduction
Grief is a natural response to loss that is complex, includes both painful and sometimes pleasant emotions, and varies over time (Bonanno, Reference Bonanno, Stroebe, Hansson, Stroebe and Schut2001; Samuel, Reference Samuel2019). Most eventually adapt to life without their loved one without the need for intervention (Shear et al., Reference Shear, Reynolds, Simon, Zisook, Wang, Mauro, Duan, Lebowitz and Skritskaya2016). However, grief reactions exist on a continuum from initially distressing but integrated over time, to unresolved and ‘stuck’ grief which includes psychological, physical, and behavioural manifestations (Granek, Reference Granek2014; Gross, Reference Gross2018). For a small but significant number of individuals, acute grief may become stuck as a ‘prolonged’ grief reaction, associated with a persisting state of dysfunction which may benefit from psychological intervention support. The severe end of this continuum is now defined within a new diagnostic construct, ‘prolonged grief disorder’ (PGD; Prigerson et al., Reference Prigerson, Kakarala, Gang and Maciejewski2021). Key indicators include intense longing or pre-occupation with the death of a loved one and marked emotional distress persisting for more than six months post loss, which does not lessen with time and leads to increasing impairment which cannot be better explained by another disorder (American Psychiatric Association, 2022; Prigerson et al., Reference Prigerson, Bierhals, Kasl, Shear, Reynolds, Day, Beery, Newsom and Jacobs1997; World Health Organization, 2022).
An estimated 10% of bereaved people develop PGD (Boelen et al., Reference Boelen, Reijntjes, Djelantik and Smid2016; Lundorff et al., Reference Lundorff, Holmgren, Zachariae, Farver-Vestergaard and O’Connor2017) and within general populations the approximate prevalence is 1–3% (He et al., Reference He, Tang, Yu, Xu, Xie and Wang2014; Rosner et al., Reference Rosner, Comtesse, Vogel and Doering2021). Contextual factors, such as personal vulnerability, relationship characteristics and context of the bereavement, can disrupt the natural healing process of mourning and exacerbate the risk of PGD (Boelen, Reference Boelen2016; Lobb et al., Reference Lobb, Kristjanson, Aoun, Monterosso, Halkett and Davies2010; Shear, Reference Shear2012). Factors that are associated with a greater risk of developing PGD include circumstances of the death (particularly death of a young person, or an unexpected and/or violent death), those with a prior history of mental health issue(s), and lack of social support following the loss (Boelen et al., Reference Boelen, Lenferink and Smid2019; Lundorff et al., Reference Lundorff, Bonanno, Johannsen and O’Connor2020; Mason et al., Reference Mason, Tofthagen and Buck2020). PGD is associated with impaired health outcomes, sleep disturbance, immune system dysfunction, reduced quality of life (QoL), increased adverse health behaviours including substance misuse, and exacerbation of co-morbid mental health issues including post-traumatic stress disorder (PTSD), depression, suicidality, anxiety, and functional impairment (Breen et al., Reference Breen, Hall and Bryant2017; Latham and Prigerson, Reference Latham and Prigerson2004; Prigerson et al., Reference Prigerson, Horowitz, Jacobs, Parkes, Aslan, Goodkin, Raphael and Maciejewski2013; Shear et al., Reference Shear, Simon, Wall, Zisook, Neimeyer, Duan, Reynolds and Keshaviah2011; Shear, Reference Shear2015). Therefore, there are substantial public health implications for untreated PGD (Lichtenthal et al., Reference Lichtenthal, Roberts, Donovan, Breen, Aoun, Connor and Rosa2024).
Despite controversy regarding the pathologising of grief, there is clear evidence that for some, bereavement-specific distress is distinct from similar diagnoses including depression or PTSD (Boelen, Reference Boelen2016; Prigerson et al., Reference Prigerson, Horowitz, Jacobs, Parkes, Aslan, Goodkin, Raphael and Maciejewski2009; Shear, Reference Shear2015) and requires treatment targeting loss-specific mechanisms. Consequently, research and clinical evaluation of PGD treatment is a priority.
Several evidence-based PGD treatments have been developed. One effective approach is prolonged grief disorder therapy (PGDT; Shear et al., Reference Shear, Skritskaya and Bloom2022), a 16-session integrated individual treatment protocol consisting of modified cognitive-behavioural, narrative and behavioural exposure, and motivational strategies. PGDT was developed in-line with new PGD diagnostic frames, underpinned by attachment theory and dual-process models of bereavement (Bowlby, Reference Bowlby1980; Kobak et al., Reference Kobak, Shear, Skritskaya, Bloom and Bottex2023; Stroebe and Schut, Reference Stroebe and Schut1999). PGDT posits that adaptation to loss may be inhibited by a range of psychological mechanisms (‘derailers’), causing individuals to become stuck in acute grief, preventing them from navigating typical healing milestones in the process of adapting to the loss. These include understanding and accepting grief, managing emotional pain, imagining a promising future, strengthening relationships, telling the story of the death, living with reminders, and connecting with memories of the deceased (Prigerson et al., Reference Prigerson, Shear and Reynolds2022). PGDT aims to identify and overcome derailers to therapeutically facilitate adaptation through a dual process of loss- and restoration-oriented treatment phases. Clients are enabled to accept the reality of the loss, whilst restoring meaningful relationships and activities in other areas of life. Evaluations to date show that PGDT is feasible, acceptable and safe, with significantly superior outcomes in three separate studies to alternative active treatments for depression (Nam, Reference Nam2015; Nam, Reference Nam2016; Shear et al., Reference Shear, Frank, Houck and Reynolds2005; Shear et al., Reference Shear, Wang, Skritskaya, Duan, Mauro and Ghesquiere2014; Shear et al., Reference Shear, Reynolds, Simon, Zisook, Wang, Mauro, Duan, Lebowitz and Skritskaya2016; Shear et al., Reference Shear, Skritskaya and Bloom2022; Supiano and Luptak, Reference Supiano and Luptak2013).
Despite the growing body of literature highlighting the prevalence and impact of stuck grief, UK service provision is lacking (Robertson and Scanlan, Reference Robertson and Scanlan2010). As the predominant provider of evidence-based psychological support for individuals with depression and anxiety in primary care settings in England, the ‘National Health Service Talking Therapies for anxiety and depression’ (NHS-TT) service provides an opportunity to examine implementation of PGDT as a treatment for PGD co-morbid with depression and anxiety.
Responding to need, a Devon NHS-TT service established a pilot grief pathway, implementing PGDT as a high intensity intervention (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025). Eighty patients who had suffered a bereavement at least six months previously and had a sustained prolonged grief response were treated over two years, with high-intensity therapists undergoing a bespoke training and supervision package. The evaluation found the intervention pathway feasible and acceptable in an NHS-TT context, with a significant, large effect size pre-to-post benefits across outcome measures for PGD, depression, anxiety, and functioning (Cohen’s d>1.04), surpassing those found in prior randomised controlled trials (Shear et al., Reference Shear, Frank, Houck and Reynolds2005; Shear et al., Reference Shear, Wang, Skritskaya, Duan, Mauro and Ghesquiere2014; Shear et al., Reference Shear, Reynolds, Simon, Zisook, Wang, Mauro, Duan, Lebowitz and Skritskaya2016). According to NHS-TT outcome metrics for combined changes in anxiety and depression, 82% of clients exhibited reliable improvement, 72% of clients showed recovery, and 68% of clients achieved reliable recovery. On the PGD measure (the Brief Grief Questionnaire; Shear et al., Reference Shear, Jackson, Essock, Donahue and Felton2006), rates of reliable improvement were 77% and rates of recovery were 63% (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025). Altogether, the service evaluation supports the potential effectiveness of embedding grief pathways into wider NHS-TT contexts. However, these promising evaluation outcomes would benefit from supplementation with qualitative data to allow for in-depth and nuanced exploration of PGDT experiences (Moore et al., Reference Moore, Audrey, Barker, Bond, Bonell, Hardeman and Baird2015; Onghena et al., Reference Onghena, Maes and Heyvaert2019; Snowdon, Reference Snowdon2015). There is a broader extant qualitative literature examining clients’ experiences of psychotherapy, but very few existing studies have focused on grief psychotherapy specifically. For example, Levitt et al. (Reference Levitt, Pomerville and Surace2016) conducted a qualitative meta-synthesis of clients’ experiences across psychotherapy types and psychological problems, incorporating reflections on 67 articles. This identified common themes around client experiences across therapy types and presenting problems, including the importance of identifying and changing behavioural patterns; validating vulnerable discussions; increasing client non-judgemental self-reflection and awareness; and the role of the therapist to support and check goal progress and providing guidance when there is client avoidance or blocks. However, there is a much smaller literature on experiences of grief support such as bereavement counselling (Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017), cognitive behavioural therapy adaptations for grief in older adults (Buur et al., Reference Buur, Mackrill, Hybholt, Nissen and O’Connor2025), and general grief support in group format (Dyregrov et al., Reference Dyregrov, Dyregrov and Johnsen2014), and none that pertain specifically to the PGDT model that is the focus of the current study. Qualitative exploration of PGDT can help to understand the impacts of treatment, assess acceptability to key stakeholders, and test and refine the underlying logic model of the intervention. In turn, this may support iterative development and refinement of the intervention to support intervention adherence and implementation in clinical trials and real-world settings. To date, no such qualitative evaluation of PGDT has been undertaken of this pathway, nor are we aware of any qualitative evaluation of PGDT in the existing literature.
To address this qualitative evaluation gap, the current qualitative interview study explored client views of PGDT for PGD within the context of a grief quality improvement project delivering PGDT in an NHS Talking Therapies (NHS-TT) service for anxiety and depression in Devon, UK. Informed by the Medical Research Council (MRC) process evaluation framework for complex interventions (Moore et al., Reference Moore, Audrey, Barker, Bond, Bonell, Hardeman and Baird2015), the study aimed to explore clients’ experience and views of PGDT via qualitative interviews to investigate the following topics:
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(1) To explore the impact of PGDT: what, if any, impact did PGDT have on grief and broader features of life like wellbeing and functioning?
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(2) To understand the context in which PGDT works: what are perceived barriers and facilitators to engaging with and benefiting from PGDT?
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(3) To explore change processes: what are clients views about how PGDT brought about any positive impacts?
In addition, any unexpected themes or perspectives that emerged were explored.
Method
Design
This study was designed in line with guidance from the MRC about how qualitative interviews can contribute to process evaluation of complex interventions (Moore et al., Reference Moore, Audrey, Barker, Bond, Bonell, Hardeman and Baird2015). To help contextualise findings, the qualitative design was supplemented by a Devon NHS-TT service’s routine clinical data, demographic characteristics, and satisfaction surveys. Semi-structured interview guides were used, topic areas derived from MRC guidance, and questions themselves were informed and shaped by consultation with Experts by Experience. The project was completed as the major thesis in the first author’s Doctorate in Clinical Psychology training (DClinPsy) at the University of Exeter.
Recruitment
ClientsFootnote 1 were recruited from a pool of 80 individuals who were allocated to receive PGDT within the Devon NHS-TT PGD pathway pilot between April 2022 and April 2024 (sample reported in Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025). Following the end of PGDT, all clients were approached by an assistant psychologist on placement within the service via email to invite them to the qualitative study. The email contained an invitation to participate with a study poster containing the details and a permission to contact form. Convenience sampling was used, and eligibility to take part in the interviews was irrespective of their degree of engagement, clinical outcomes, and therapy discharge code. For clients who had not responded to the initial email invitation within two weeks, the assistant psychologist contacted them via telephone to invite clients to the interview. No a priori sample size was set as the intention was to keep interviewing until data saturation was reached (whilst also considering the pragmatic constraints introduced around completing the project to align with DClinPsy thesis submission of the first author).
Data collection
Qualitative data
Qualitative interviews followed a semi-structured but flexible topic guide (see Supplementary material, SOM 1) to ensure broad experiences of treatment were covered, which was informed by interview topic guides used in process evaluations of other psychotherapies used within our centre (Demetriou et al., Reference Demetriou, Widnall, Warbrick, Reed, Marchant, Geschwind and Dunn2025) and was piloted prior to the study. This consisted of open-ended questions and follow-up prompts to facilitate individuals discussing issues they felt important. There was also space in the interviews to explore any unexpected experiences of themes not incorporated in the topic guide. The topic guide was updated over the course of the study, as a result of emerging themes from interim analysis and reflection. Open-ended questions enquired about general experiences of treatment, impacts of treatment, aspects of treatment experienced as helpful and unhelpful, nature of the therapeutic alliance, and finally facilitators and barriers to engaging with treatment. Interviews lasted approximately 45–60 minutes.
Client satisfaction rating
The Client Satisfaction Questionnaire-8 (CSQ-8) is an 8-item measure adapted for both clients and therapists in this study to determine views on acceptability of PGDT and the grief care pathway. Using a 4-point scale, possible scores range from 8 to 32, with greater scores indicating higher satisfaction (Larsen et al., Reference Larsen, Attkisson, Hargreaves and Nguyen1979). The CSQ-8 is a reliable and valid measure of client satisfaction and acceptability in out-patient mental health services, with high internal consistency (Cronbach’s alpha=0.95; Pedersen et al., Reference Pedersen, Havnen, Brattmyr, Attkisson and Lara-Cabrera2022).
Demographic information
Client demographic surveys captured age, gender, ethnicity, use of medication for mental health, employment status, relationship status, highest level of education, previous therapy experience, and bereavement details (relationship to the deceased, sudden or traumatic loss, and time since loss).
Clinical data
Routine clinical data related to engagement in therapy (number of sessions attended), therapeutic ending (planned discharge or drop-out), and response to treatment (pre- and post- treatment symptom severity and functional impairment scores) were provided by the Devon NHS-TT service. The routine NHS-TT minimum dataset includes the Patient Health Questionnaire to index depression (PHQ-9; Kroenke et al., Reference Kroenke, Spitzer and Williams2001), the Generalised Anxiety Disorder Scale to index anxiety (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006), and the Work and Social Adjustment Scale (WSAS; Mundt et al., Reference Mundt, Marks, Shear and Greist2002) to assess functional impairment related to mental ill health administered at every treatment session. This was optionally supplemented with the Brief Grief Questionnaire (BGQ; Shear et al., Reference Shear, Jackson, Essock, Donahue and Felton2006). The BGQ is a 5-item self-report questionnaire typically used to screen for prolonged grief symptoms and was also used at assessment and the final treatment session in the Devon NHS-TT grief pathway to evaluate impact on grief scores. Higher scores indicate a greater grief reaction, scores <4 means prolonged grief is unlikely, scores 4–7 indicate a mild prolonged grief reaction and scores of ≥8 indicate a severe grief reaction. A score of ≥4 was used to assess eligibility to the Devon NHS-TT grief pathway. The BGQ was not available through the NHS-TT electronic data capture system which resulted in slightly higher rates of missingness in the overall sample (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025) and the subsample interviewed.
Procedure
Potentially eligible participants were provided a study leaflet, permission to contact form, and participant information sheet detailing the research, consent, and confidentiality procedures. Those interested could contact the researcher directly by email or return a signed permission to be contacted form. The researcher (first author) offered a meeting to discuss participation or research queries before gaining written informed consent. Informed consent included consent for the researchers to request routine clinical data recorded by NHS-TT. Once informed consent was provided, clients were invited to interview with the researcher. All clients were given the choice of an in-person, telephone or videoconference for the interview. Nine of the eleven clients participated by videoconference, one was interviewed via telephone and one via an in-person interview. The researcher received training and guidance in qualitative interviewing and analysis from co-authors who had expertise in qualitative research methods. The first author also had prior experience of conducting qualitative interviews and analysis in three previous projects focused on improving service provision. The interviewer had no prior relationships with participants, with the exception of the Devon NHS-TT service lead (co-author). Clients interviewed were informed of the research aims in the study information sheet and provided written, informed consent. Following informed consent, the CSQ-8 and demographic surveys were administered and then the interview was conducted.
Interviews were audio recorded using an encrypted recording device, moved to a secure server, and then transcribed verbatim by a professional transcriber. All clients were sent their transcripts for comment and/or correction over a two-week period following the interview. One client corrected typographical errors that may have obscured clarity in the message they were trying to convey, and this transcript was amended in line with the feedback. Then all transcripts were anonymised.
No client approached for the study refused to participate, nor did anyone drop out. A post-study letter and voucher reimbursement (£10 online Love2Shop voucher) were provided at the end for all clients who participated in the interviews.
Service user consultation
The Doctorates in Psychology (DCPGR) Lived Experience Group at Exeter University (individuals with lived experience of mood disorders who co-design research alongside professionals) was consulted about this study at the design stage and an expert collaborator with personal experience of PGD contributed to the design, materials, study conduct, interpretation of finding, and dissemination of findings. This involved ensuring compassionate use of language, emphasising questions are voluntary, welcome/introduction calls prior to participation, and peer-review of analytic findings in line with good practice guidelines (Burnham et al., Reference Burnham, Marchant, Oliver, Ryan and Dunn2025; Sheldon and Harding, Reference Sheldon and Harding2010). The service user collaborator was reimbursed for their time at a rate of £20 per hour.
Data analysis
The demographic characteristics and CSQ ratings were presented descriptively. To avoid clients being identifiable, individual level participant demographics are not reported. As there is no consensus as to what an adequate minimum dose of PGDT is, we report a liberal estimate of completing four or more sessions of treatment, and a conservative estimate of those who received at least 50% of acute treatment dose (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025). Clinical outcomes were assessed in terms of change from intake to final treatment session PHQ-9, GAD-7, WSAS and BQG. The binary outcomes presented are reliable improvement, reliable deterioration, recovery (scoring below clinical cut-offs at last treatment session) and response (≥50% reduction in symptoms between first and last session). Additionally, we report NHS-TT routine outcomes which pools depression and anxiety scores. This included reliable improvement (either PHQ-9 or GAD-7), recovery (scoring above the clinical threshold on the PHQ-9 and/or GAD-7 at intake and the final outcome score moving below the clinical threshold on both PHQ-9 and GAD-7) and reliable recovery (both reliable improvement and reliable recovery).
A thematic framework method (FM) was used to analyse the qualitative data drawing from Braun and Clarke’s thematic analysis approach (Braun and Clarke, Reference Braun and Clarke2006). The FM approach takes an integrative deductive and inductive approach to ensure the researcher’s questions are adequately addressed, whilst ensuring there is space to explore the interviewee’s broader experiences of PGDT. This allows for in-depth exploration of individual experiences, while also drawing out broader practical clinical and service implications (Gale et al., Reference Gale, Heath, Cameron, Rashid and Redwood2013; Ritchie et al., Reference Ritchie, Lewis, Lewis, Nicholls and Ormston2013). FM has no pre-determined theoretical or epistemological position, thus reflexivity and mindful engagement with the data is imperative. FM outlines an approach for flexibly yet systematically categorising data, evolving themes as new insights emerge, and is well-suited to clinical service research as it can be adapted flexibly to suit the needs of the study. A pragmatic approach was adopted, aiming to develop a practical understanding of concrete, real-world issues to inform action (Kelly and Cordeiro, Reference Kelly and Cordeiro2020) while at the same time recognising that an objective reality cannot be comprehended fully due to the impossibility of eliminating any researcher’s subjectivity to the analytical process (Guba and Lincoln, Reference Guba and Lincoln1994).
An overall working analytical framework was developed consisting of hierarchical structure of themes, sub-themes and codes to guide the interview coding process. This framework was informed by the research questions and existing literature. All interview transcripts were analysed using NVivo software (Lumivero, 2023) to support systematically applying the analytical framework to the interviews. To identify recurring patterns in client and therapist interviews, Gale et al.’s (Reference Gale, Heath, Cameron, Rashid and Redwood2013) seven-stage process was followed: (1) transcription and immersion, (2) familiarising (re-reading, mind-mapping, reflexive note-keeping), (3) inductive and deductive coding, (4) categorising and refining codes into frameworks, (5) applying coding frameworks to datasets in NVivo and refining further as necessary, (6) developing a matrix, and (7) interpretation through repeated mapping of theoretical concepts to identify synergies and differences between emerging themes. Thematic flowcharts for client interviews were developed and then further analysed with input from expert collaboration. A comprehensive thematic framework flowchart was developed to cohesively present over-arching themes across patient data (Braun and Clarke, Reference Braun and Clarke2021). This analysis was submitted by the first author for a DClinPsy qualification and then condensed for the current manuscript. To retain equipoise in the analysis and to maximise a critical analysis of PGDT (cf. Demetriou et al., Reference Demetriou, Widnall, Warbrick, Reed, Marchant, Geschwind and Dunn2025), at the stage the current manuscript was drafted interviews were revisited from participants who did not show reliable improvement on any of the outcome measures or who have mixed or negative satisfaction ratings.
Reflexive statement
The study is underpinned by contextualist epistemological and critical realist ontological principles. Adopting this stance posits that reality exists independently of human thought, although our understanding of it is inherently subjective (Larkin et al., Reference Larkin, Watts and Clifton2006). Hence, the first author sought to explore the subjective realities of client perceptions and experiences, whilst recognising that knowledge and meaning are embedded within specific social contexts. Reflexivity and transparency of positionality is therefore crucial, in acknowledging the researchers’ own experiences and narratives that may impact interpretation of findings (Braun and Clarke, Reference Braun and Clarke2006; Braun and Clarke, Reference Braun and Clarke2013).
As a research-practitioner, the first author’s professional background is working within ‘service gaps’ to advocate and improve access for often-excluded groups. Although the cultural context largely aligns with the clients and therapists within this study; as a white, working-class woman with informal caring responsibilities and lived experience, the first author’s position is that communities should actively bridge these service gaps with evidence-based services that meet the needs of people living with complex difficulties. However, differences in educational attainment, occupation, and age mean this may be different to some clients and therapists in terms of social power and privilege.
To mitigate potential biases, continual reflexive journalling and supervision, expert collaboration, peer-review, and feedback from clinicians and researchers attending the BABCP conference enabled a diverse range of perspectives to enhance the analysis, rigor, and validity of findings (Burnham, Reference Burnham2018; Braun and Clarke, Reference Braun and Clarke2019). To improve credibility, thick participant descriptions are presented to enhance transferability (Nowell et al., Reference Nowell, Norris, White and Moules2017).
Results
Client characteristics
The qualitative interviews were conducted between August 2023 and December 2023 and all clients received PGDT within 18 months prior to interview. In total, 11 clients participated in the interviews.
The group level demographic and clinical characteristics are shown in Table 1 (see SOM 5 Table S1 for individual level previous therapy and bereavement contextual factors). Clients interviewed were predominantly White British, female, and a mix of ages. Most were employed full-time, in a relationship, and had received prior therapy before entering the PGD pathway. The cause of death was predominately due to medical conditions or illness (10/11; 90.9%) and one accident (1/11; 9.1%). The mean number of years since loss occurred was around 10 years, approximately half were bereaved of a child, and all but one client described their loss as sudden or traumatic.
Table 1. Group level demographic and clinical characteristics of PGDT clients
PHQ-9, Patient Health Questionnaire; GAD-7, Generalised Anxiety Disorder Scale; WSAS, Work and Social Adjustment Scale; BGQ, Brief Grief Questionnaire; reliable improvement, pre–post treatment scores reduced by the reliable change criteria of that measure (PHQ=6 points; GAD-7=4 points); reliable deterioration, pre–post scores increased by the reliable change criteria for measure; recovery, scoring below clinical cut-offs (PHQ-9=<10; GAD-7=<8) at last treatment session; response=≥50% reduction in symptoms between first and last session; NHS-TT, National Health Service Talking Therapies for anxiety and depression; NHS-TT reliable improvement, reliable improvement in either PHQ-9 or GAD-7 scores; NHS-TT recovery, recovery on both PHQ-9 and GAD-7 scores; NHS-TT reliable recovery (both NHS-TT reliable improvement and recovery); CSQ, Client Satisfaction Questionnaire. aThere were no BGQ data for two clients
Reflecting strong engagement, all clients (11/11; 100%) received the minimum dose of ≥4 sessions and 8/11 (73%) clients attended 50% (8/16 sessions) or more treatment sessions (mean number of sessions attended=11.09 (SD=4.21)). All clients in this subsample were classed as therapy completers because they had a planned discharge and/or received full course of treatment (see Supplementary material, SOM 5 Table S2 for individual level therapy engagement and clinical outcome data). The client subsample interviewed (Table 1) had broadly similar positive clinical outcomes to the total client sample reported in the quantitative evaluation of the PGD pathway (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025), with both samples showing clinically meaningful reductions in depression, anxiety, grief and functional impairment (see Supplementary material, SOM 5 Table S3). No participants exhibited reliable deterioration on any outcome measure (Table 1). Within the subsample interviewed, 9/11 met NHS-TT reliable improvement criteria and 10/11 showed reliable improvement on at least one of the PHQ-9, GAD-7, WSAS and BGQ. Only one participant (CP11) did not show reliable improvement on any measure. For two clients, the BGQ outcomes were not available.
All clients rated PGDT as highly satisfactory on the CSQ (Table 1; see Supplementary material, SOM 5 Table S4 for individual level CSQ item ratings and total score) reflecting high satisfaction for the therapy model, format, delivery, and effectiveness. In particular, all clients rated the intervention quality as good or excellent; all were definitely satisfied with the NHS-TT service; 9/11 clients would definitely consider using NHS-TT again (the remaining two stating, ‘I think so’); all clients stated the intervention met most or almost all needs; all were mostly or very satisfied with their therapist; all bar one would definitely recommend PGDT (one stating, ‘I think so’); 9/11 stated PGDT definitely reduced symptoms and two said PGDT somewhat reduced symptoms. The total CSQ score was rated as very high for all 11 clients.
As outlined in the analysis section, the client interview of CP11 (the one client who did not show reliable improvement on any outcome scales) was revisited to retain equipoise and a critical stance in the analysis. Quotes from CP11 are marked with an asterisk (*).
Framework analysis findings
Five over-arching themes emerged from the analysis (Table 2).
Table 2. Identified themes, sub-themes and illustrative quotes
1. Life Before: Stuck Grief
Clients spoke of their profound sense of ‘stuckness’ before treatment. Many felt isolated and disconnected from life and themselves, unable to function or engage meaningfully in the world. Attempts to intellectualise grief often led to persisting distress and an inability to move on:
CP10: ‘In the world, but not part of it … disassociated … The world was grey … I thought I could intellectualise my way out…’
The burden of unresolved grief caused some to view their future as bleak and meaningless. However, clients’ strong motivation to change and reclaim their lives was apparent:
CP6: ‘For fifty years, I’d been carrying this around with me … My whole life just fell apart … I’ve never had a future … I couldn’t visualise it … but I HAVE to do something … I can’t numb myself to it anymore … I’ve got to be able to live a life.’
2. Changes to Wellbeing and Quality of Life.
Clients described PGDT as having a powerful impact on wellbeing. Perception, functioning, and QoL was unexpectedly transformed for the overall majority:
CP10: ‘I felt like I re-entered slowly and like almost imperceivably. But just felt like I came back into the planet a bit more.’
Moreover, wellbeing was sustained or better than before the loss occurred. Self-compassion and an unburdening of guilt came through strongly in client interviews:
CP6: ‘A happier life! A life without carrying a burden.’
2.1. Prolonged to Integrated Grief
As their loss and grief were accepted and integrated into their lives, clients were able to honour their grief without it dominating their lives:
CP6: ‘The grief I had in the past, was a “dishonest” grief. It was about trying to deny the fact that life comes to an end … So, my grief now is … an “honest” grief … When you carry something for that long it becomes a part of you … that’s a great feeling … To put it down and to walk away …’
Clients also reflected on the ‘journey’ of mourning, the dynamic, enduring nature of profound loss. For some clients the imaginal conversation supported them to accept the reality of their loved one’s death and balance grieving with moving forwards, keeping loved ones’ memory alive with new traditions, and pain transformed into strength and resilience.
CP6: ‘He’s sort of saying goodbye … my life’s over. But yours is just beginning. Carry on. Do the things I can’t do. And live your life with me in mind …’
2.2. Re-Claiming Life and Future.
Clients felt they had ‘permission’ to reclaim a purposeful life, despite their loved one no longer being beside them. Re-establishing or forming new social connections, valued pursuits, and visualising and planning for a hopeful future again:
CP6: ‘When you don’t have a future … You CANNOT imagine it … to have that changed is err … it’s life-changing! … I want to be there! I’d like to be there, you know?!’
2.3. Personal Growth: Resilience, Motivation, Agency
Clients emphasised how PGDT empowered them to grow and self-reflect. With new-found determination, clients pursued previously unfathomable changes in their broader life:
CP7: ‘Cos, you know, I’m more eager to try - try things I wouldn’t normally have tried you know … I realised I was more and more confident … So, I’ve handed my notice in to the Army. I’m out next year.’
The transformative impact on clients was further apparent in their deep gratitude for PGDT and motivation to advocate for wider access:
CP4: ‘I just thought how wonderful it was. How inspiring it was … I definitely recommend it … it helped me massively, I’m just grateful. So, please let it continue … to the rest of the country!’
2.4. An Ongoing Recovery Journey
Some clients saw therapy as a challenging but useful first step to process the loss and continue with life:
CP11: ‘You know, it’s been hard! Don’t get me wrong! It’s not all been a bed of roses! But even though I said … I’m not there yet, I’m getting there’ *
3. Barriers and Facilitators of PGDT Engagement.
This theme explores what clients and therapists felt were particular barriers or facilitators to therapeutic engagement and progress, organised into subthemes ‘contextual modifying factors’, ‘helpful’ and ‘challenging’ aspects of PGDT.
3.1. Contextual Modifying Factors
Clients’ ability to integrate PGDT practice into their lives appeared to mediate treatment efficacy and satisfaction. Individual life contexts including support resources, capacity, co-morbidities, specific loss circumstances, and sometimes avoidant coping patterns impacted readiness or ability to engage with the emotional intensity and certain aspects of treatment:
CP4: ‘I couldn’t have done it without having a period of time off work. Because it was very reliving and traumatic at times.’
3.2. Helpful Aspects
Tailoring the pace, structure, and homework tasks to work with individual strengths and needs appeared to enhance engagement, progress, and satisfaction with treatment. Therapists’ collaboration and flexibility was valued, appearing to moderate helpful and challenging aspects of treatment and strengthened the therapeutic relationship:
CP1: ‘The most important parts were that it was completely tailor-made for me.’
The containing space to voice and process complicated emotions was important. Although the intensity and vulnerability were challenging, working through supressed feelings unburdened clients and enabled significant change:
CP7: ‘I was able to talk about stuff that I’d never spoken about before.’
CP11: ‘… it felt freeing. The fact that I could sit in a chair and cry for half an hour. It was just that you can let everything pour out.’ *
While sometimes arduous, clients acknowledged the motivational impact of visible progress in grief monitoring scores. Moreover, reflecting in-between therapy sessions enhanced self-insight and pro-active engagement, which reinforced and accelerated therapeutic gains:
CP10: ‘Homework exercises often led to breakthroughs for me. I’d come back to my sessions with new insights and questions.’
Clients found PGDT an acceptable treatment that effectively targeted the core grief maintenance processes. Many appreciated the variety of techniques and comprehensiveness of PGDT comparative to other therapies not tailored to the nuances of grief-specific sequalae:
CP1: ‘It’s like finding the right book … suddenly you think yeah, that’s what I’ve been looking for all this time.’
Furthermore, PGDT’s structure and logical flow provided clear expectations and containment, with initial phases preparing for more intensive revisiting sessions:
CP8: ‘Everything followed a logical pattern. It kind of made sense to do the stuff we were doing when we were doing it.’
3.3. Challenging Aspects
Paperwork sometimes felt repetitive and laborious; clients felt streamlining and tailoring administrative tasks would lessen this burden, particularly where life circumstances or phase of therapy made navigating this more difficult:
CP3: ‘Way too many [forms to complete]! Too complicated! … I can’t do all of that and process!’
Some clients found endings challenging. Despite planned discharges providing some containment, further sessions or follow-ups were wished for, and not all clients felt they had received enough therapy:
CP1: ‘I feel a huge loss for [therapist]! I was so attached to him [therapist]! I kept thinking … do we really have to finish?”
CP11: ‘I feel I could have done with more sessions … it could have lasted a little bit longer.’ *
4. Perspectives of Change Processes in PGDT
Sub-themes emerged around PGDT aspects that elicited the most therapeutic change.
4.1. Normalising and Validating Grief Perspective Shifts
Normalising and validating grief experiences enabled clients to better understand their complex and conflicting feelings about their loss, which changed their perception of grieving, instilling self-compassion rather than judgement.
CP1: ‘He [therapist] just sort of managed to bring me to a place of compassion really. When he [therapist] said this is an appalling thing that you’ve been through you know. You’ve had to cope with this all on your own.’
CP11: ‘Especially the survivor’s guilt … The more she explained, the more I was … saying to myself, actually, that makes sense now… It made me open my eyes, if that makes sense? … It was an education! A valuable one!’ *
Learning about PGD and the processes of moving through acute to integrated grief with PGDT enabled a shift from scepticism to hope that change is possible, encouraging engagement and buy-in to the therapeutic process:
CP5: ‘I thought this is finally going to shift something for me … I wasn’t quite so lost as I thought … somebody knew where I was and was going to help me out of it!’
4.2. Meaningful Life Engagement through Choice, Goals, and Values
Restorative components (i.e. reconnecting to wellbeing and life) worked with client’s own theory of change, enabling them to work towards meaningful goals and values, while fostering a sense of accomplishment and agency when therapists incrementally review progress:
CP3: ‘Goals at the beginning are really important … You’ve got to know what you’re working towards … Like, she [therapist] challenged my mindset … Would you consider registering on a dating site? I said to her [therapist], I’ve done it! I can’t believe I’ve done it!’
4.3. Social Connection as a Key to Change
There was an emphasis on human connection, both in and outside of therapy, as being a key to change in unresolved grief. A trusting, secure therapeutic relationship was crucial for clients to engage with the emotional intensity of PGDT. Therapists’ compassion, patience, kindness, appropriate self-disclosure, and genuine curiosity was particularly valued:
CP6: ‘I surrendered to her [therapist] … I felt safe with her [therapist] … I had immense trust. She [therapist] wouldn’t lead me anywhere that she [therapist] couldn’t get me home from.’
Connection with wider support networks encouraged clients to express grief openly. While bringing loved ones to sessions was initially uncomfortable, it often became a turning point, and clients became more comfortable discussing their loss, feeling understood, and re-engaging socially:
CP8: ‘I really dug my heels in about bringing a friend in … And that actually was more helpful than I thought … to hear what she [friend] thought and to have those conversations … It’s okay to talk about them … it’s okay to ask for help.’
Finally, connection with the lost loved one, by honouring them in the therapeutic space helped facilitate the natural mourning process. Reminiscing enabled clients to reframe overwhelmingly negative memories and ruminations, and access positive, treasured moments, even making new memories in honour of the deceased. Eventually, clients could express grief without the distress re-activating their avoidance. The imaginal conversation session was often quoted as challenging but powerful:
CP6: ‘Through the therapy … I changed that memory to a different memory entirely. Which was, me, warm and safe in that same situation. Seeing my brother and saying goodbye … Anytime I want to see him, I can see him.’
4.4. Facilitated Mourning: Denial and Avoidance to Acceptance and Approach
Identifying derailers and engaging in exposure was crucial for clients to move from denial and avoidance to acceptance and approach – actively confronting their grief, thereby facilitating the natural mourning process. They gained clarity and more self-compassionate understanding of where their mourning ‘got stuck’:
CP1: ‘I was shutting myself down emotionally … that’s why I was so stuck … you have to surrender to the grief … You can’t fight it.’
Revisiting sessions and home practice was considered the most difficult for clients to engage with, but a deeply powerful therapeutic tool for processing traumatic loss memories and moving clients into integrated grief, which reduced distress and fostered acceptance:
CP3: ‘It didn’t feel like it was my narrative. My story. I felt really disconnected from it … the more I listened … the more acceptance I had.’
CP11: ‘Having to hear it over the phone and relive it through the counselling sessions … Honestly, even though it benefited me towards the end, at the time I felt my heart was being ripped out of my chest … That was the hardest part … But it made the most difference.’ *
Therapists creating a safe, containing space, normalising the bereavement process, and using grounding imagery techniques enabled clients to overcome avoidance and fear around engaging with this process:
CP3: ‘I was safe … I felt in control … I didn’t finish that session feeling traumatised, emotional, drained … I was okay … for me, it worked brilliantly.’
4.5. Empowering and Building Coping
Clients thought PGDT equipped them with tools for self-regulation and ongoing, sustained wellbeing. Enhanced coping supported clients to build confidence in recognising, confronting, and responding to grief triggers in day-to-day life that were previously avoided:
CP9: ‘Therapy has given me tools … I now feel more able to cope with the different feelings and accept what they are.’
CP11: ‘The counselling has taught me ways of dealing with the everyday, dealing with people, dealing with my friends’ *
Clients reported developing curiosity, compassion, and mindful observation skills, applying these to grief-specific difficulties but also enabling growth and resilience to make positive changes to their lives and feel more able to tackle broader life challenges both in the present and future:
CP7: ‘He [therapist] said: “you’re not going to see me forever … this is where you need to stop and think for yourself!”, which was like properly handy! … Now I’m more tolerant … to everyday problems … that used to feel like the end of the world.’
5. The Grief Gap: A Distinct Therapeutic Offering
Clients noted their previous support for grief was non-directive, more general with fewer support strategies and less focused on grief:
CP1 [in discussing previous counselling therapy]: ‘But they don’t seem to give you any strategies, or help you to, you know, move on.’
Clients also commented that compared with previous support, PGDT was more focused and personalised:
CP4: ‘Yes, so the prolonged grief therapy was more appropriate for me … it’s a lot more focused. And, there’s specific things you’re covering … that wouldn’t have come out of any counselling, or any counsellor really. It needed to be the grief therapy. Something much more focused and individualised.’
Clients commented that the offering should be more widely available, not just an implementation pilot in one area:
CP11: ‘Bereavement counselling shouldn’t just be in one area. It should be everywhere.’ *
In this pilot, clients were offered different types of NHS-TT therapies, particularly where co-morbid symptoms of PTSD or depression were present. This fit well with current NHS-TT practice and facilitated pro-active engagement because clients were personally motivated to engage in the offering, they felt was best suited to their needs:
CP4: ‘I was given the choice … if you still feel that you need further support around potential PTSD, then do get back in touch. So, it was never like this is the only option that we’ll offer you.’
Discussion
This study provides the first qualitative evaluation of PGDT, exploring client views of PGDT delivered in a UK NHS-TT context (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025).
Clients interviewed were a mixture of ages, mostly female, and the majority were of White British ethnicity which on the whole reflects the sample treated by Devon NHS-TT services. All clients interviewed engaged well with therapy, and 11 out of 12 showed reliable improvement on at least one clinical outcome measure (depression, anxiety, grief, or functional impairment). The remaining client did not improve on any outcome measure; no clients showed reliable deterioration on any measures. Additionally, clients rated PGDT and the broader service pathway as being highly acceptable on quantitative satisfaction ratings. These positive outcomes mirror promising clinical results in the broader audit sample (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025).
Overall, five over-arching qualitative themes were identified (Table 2) which can potentially be used to improve and refine PGDT and its implementation in an NHS-TT context through reference to the UK MRC process evaluation framework (Moore et al., Reference Moore, Audrey, Barker, Bond, Bonell, Hardeman and Baird2015). This provides a structured framework to explore how a complex intervention like PGDT leads to its effects (impact), understanding the context in which the intervention works or aspects that might hinder this process (contextual modifying factors), ways in which the intervention may work to achieve the outcome (Perspectives on Change Processes), and implementation in practice. The themes will be discussed in turn, in relation to these process evaluation frameworks components.
Themes 1 (‘Life Before: Stuck Grief’) and 2 (‘Changes to Wellbeing and Quality of Life’) capture the impact PGDT made as seen by clients. They capture the overall therapeutic journey from prior to PGDT and throughout treatment. Clients voiced how PGDT facilitated mourning to process their loss and reported moving from an isolating state of ‘stuckness’ to a more resolved and integrated grief, and honouring lost loved ones meaningfully, in a new way (Theme 1). Consistent with the psychotherapeutic concept of ‘continuing bonds theory’, healthy resolution to grief involves maintaining one’s connection to the deceased in daily life. Through mourning rituals, reminiscing, and re-engaging with meaningful social and valued activities, wellbeing and functioning is eventually restored (Klass et al., Reference Klass, Silverman and Nickman1996).
Clients also described the treatment as having a big impact on wellbeing and broader functioning. These perspectives align with empirical evidence demonstrating PGDT’s efficacy in repairing psychological functioning and alleviating co-morbid symptoms by addressing the key underlying maintenance factor – unresolved grief (Shear et al., Reference Shear, Frank, Houck and Reynolds2005; Shear et al., Reference Shear, Wang, Skritskaya, Duan, Mauro and Ghesquiere2014; Shear et al., Reference Shear, Reynolds, Simon, Zisook, Wang, Mauro, Duan, Lebowitz and Skritskaya2016; Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025). Clients emphasised the multi-faceted impacts QoL (Theme 2), personal growth (Theme 2.2) and resilience, reclamation of a meaningful life (Theme 2.1), and self-actualising hopes for the future. This captures the interplay between core components of mental wellbeing and QoL in wellbeing theories (for example, Ryff and Keyes, Reference Ryff and Keyes1995), in particular interactions between positive emotion and satisfaction with life (emotional wellbeing), individual functioning and self-realisation (psychological wellbeing), and social functioning and value (social wellbeing). Reflective of this, clients reported how building capacity for self-regulation, validating and accepting loss, and working towards values-based goals not only built confidence and skills but also enabled clients to engage with trauma-processing phases safely and meaningfully. The impact of treatment on both reducing symptoms of grief and enhancing wellbeing also aligns with the dual process model of bereavement that underpins PGDT, which proposes two interlinked tasks of mourning are to process the loss and reconnect to life (Stroebe and Schut, Reference Stroebe and Schut1999). It also aligns with the dual continuum model of mental health which proposes that positive mental health (wellbeing) and mental illness (symptoms) are partly orthogonal from one another (Keyes, Reference Keyes2017; Westerhof and Keyes, Reference Westerhof and Keyes2009), with both needing to be addressed to help individuals move to integrated grief. The client (CP11) who did not show reliable improvement on any outcome measures nevertheless reported significant benefits from therapy, a useful step in moving on with life but not yet the end of the journey.
There were a number of contextual modifying factors that helped or hindered engaging with and benefiting from the therapy noted by clients in Theme 3 (‘Barriers and Facilitators of PGDT Engagement’). Key facilitators included the structured, logical, collaborative grief-tailored approach (Theme 3.2), combining varied techniques and staged-phases that target the multi-faceted features of PGD reactions. For example, the most challenging element of treatment, prolonged exposure to triggers and trauma memories, elicited significant change. Adapting and tailoring the therapeutic approach to meet the individual rather than rigidly following a ‘diagnosis/protocol’ appears to foster better outcomes and general satisfaction in grief therapies (Neimeyer et al., Reference Neimeyer, Breen, Milman, Steffen, Milman and Neimeyer2022). Altogether, this underscores the importance of PGDT’s phased and integrative approach combining restoration-focused (Deci and Ryan, Reference Deci and Ryan2000) and cognitive behavioural techniques for emotional processing and cognitive restructuring in building resilience and coping (Beck, Reference Beck1979; Boelen et al., Reference Boelen, Lenferink and Smid2019). The multi-faceted components of PGD reactions perhaps enabled therapists to work collaboratively and flexibly within clients’ individual zones of proximal development (Vygotsky, Reference Vygotsky1980). This appeared to support clients to safely explore deep emotions, engage with challenging and burdensome homework tasks, and contain the therapeutic ending in a way that maximised positive engagement and outcomes (Norcross and Wampold, Reference Norcross and Wampold2019).
Clients noted challenges related to life circumstances and grief-related characteristics (Theme 3.1), such as specific-loss contexts, co-morbidities or external life factors like socio-economic difficulties or navigating work and home commitments impeded their ability to access the time, space, resources, and capacity to engage with PGDT. The Stress-Buffering Hypothesis (Cohen and Wills, Reference Cohen and Wills1985) suggests socio-economic status, support and financial stability, and access to more coping resources may influence treatment effects in psychosocial interventions by mitigating distress tolerance, particularly during an intensive and in-depth therapy like PGDT. Unmet complex social, personal, and economic difficulties may impact a clients’ capacity to engage therapeutically and develop emotional, psychological, and social domains of wellbeing that are key to repairing PGD. Thus, it is important that clinicians consider the significance of wider biopsychosocial factors.
With regard to processes of change, clients’ views of the possible ways in which PGDT worked largely aligned with the treatment’s logic model. Each sub-theme within Theme 4 (‘Perspectives of Change Processes in PGDT ’) clearly links to processes of facilitating adaptation to loss outlined by the PGDT healing milestones (Prigerson et al., Reference Prigerson, Shear and Reynolds2022). Clients described normalising and validating shifts perspectives (Theme 4.1), linking to PGDT’s aim of understanding and accepting grief links. Clients spoke of meaningful engagement though choice, goals, and values (Theme 4.2), aligning with the emphasis in the PGDT logic model of imagining a promising future. Clients also highlighted that connection (clients largely spoke of the positive therapeutic connection with the therapist) was a key to change (Theme 4.3), which is consistent with strengthening relationships in PGDT. Clients noted PGDT facilitated mourning and supported moving from denial and avoidance to acceptance and approach (Theme 4.4), which links with the PGDT logic model through the telling of the death story and living with reminders of the deceased. Lastly, clients described feeling empowered and able to build coping strategies for ongoing self-regulation and wellbeing (Theme 4.5) which aligns with PGDT’s aim to support managing emotional pain.
The significance of human connection in healing was a salient theme, consistent with PGDT’s and broader grief intervention attachment theory underpinnings (Levy and Johnson, Reference Levy and Johnson2019; Shear and Shair, Reference Shear and Shair2005; Stroebe et al., Reference Stroebe, Schut and Stroebe2005). Client-perceived positive therapeutic relationships are potentially explained by the formation of safe, secure attachments and positive relational enactments which may have a reparative impact on attachment wounds from bereavement. Furthermore, connection with the deceased in the therapeutic space, particularly during ‘imaginal conversation’ sessions, may indicate the role of the dialogical self in narratively reconstructing clients’ identity post-loss within the safety of a containing therapeutic space, enabling clients to re-integrate social and community activities (Hermans and Hermans-Konopka, Reference Hermans and Hermans-Konopka2010). Through an object-relational lens, this aligns with the idea that facilitated mourning within secure therapeutic relationships can re-establish an internalised sense of safety and stability of the ‘self’ and ‘others’ that is disrupted when significant attachments are lost, allowing for healthier and more adaptive ways of relating to others and re-integration to social activities (Klein, Reference Klein1940; Ogden, Reference Ogden2021).
Comparing analytic findings with PGDT’s logic model clearly substantiates the reparation of PGD through a combination of a collaborative and strong therapeutic relationship; values-driven goal-setting that re-integrates clients into life; alongside systematic exposure to the reality of the loss. The first-hand, lived experiences of both receiving and delivering the treatment supports PGDT’s dual-process theory-driven hypothesis: combining loss-oriented and restoration-oriented therapeutic activities is a demonstrably efficacious approach to resolving PGD presentations (Prigerson et al., Reference Prigerson, Shear and Reynolds2022; Stroebe and Schut, Reference Stroebe and Schut1999).
The emerging themes from clients’ experiences of PGDT are broadly comparable to the wider qualitative literature examining clients’ experience of psychotherapy and experiences of grief support outside of PGDT. Clients noted therapist collaboration with the client and flexibility tailoring treatment (Theme 3.2) was important and was similarly observed in bereavement counselling (Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017). Therapists also actively supported clients to create social connections; this included the client–therapist relationship (Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017), with the deceased (Buur et al., Reference Buur, Mackrill, Hybholt, Nissen and O’Connor2025), and outside therapy relationships (Themes 2.2 and 4.3; Dyregrov et al., Reference Dyregrov, Dyregrov and Johnsen2014; Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017; Levitt et al., Reference Levitt, Pomerville and Surace2016). In other qualitative studies clients also noted therapists’ professionalism, authority and leading the therapy was important (Buur et al., Reference Buur, Mackrill, Hybholt, Nissen and O’Connor2025; Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017; Levitt et al., Reference Levitt, Pomerville and Surace2016), and when therapy facilitators were vague, unprofessional or lacked knowledge of therapy delivery, this created barriers to engagement (Buur et al., Reference Buur, Mackrill, Hybholt, Nissen and O’Connor2025; Dyregrov et al., Reference Dyregrov, Dyregrov and Johnsen2014). Personalised treatment goals supported therapy progress review (Theme 4.2) and was noted in the wider client experience of psychotherapy outside grief support (Levitt et al., Reference Levitt, Pomerville and Surace2016) but not in bereavement counselling (Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017) which was highlighted in the current study when discussing what was missed in previous grief support (Theme 5). Clients noted validation and normalisation of grief reactions (Theme 4.1), and the bereavement process was important (Theme 4.4) which was also found outside PGDT in CBT groups for complicated grief (Buur et al., Reference Buur, Mackrill, Hybholt, Nissen and O’Connor2025) and grief support groups (Dyregrov et al., Reference Dyregrov, Dyregrov and Johnsen2014). Clients also highlighted accessing support for their grief helped to reclaim their lives (Theme 2.2), learning how to live again while honouring the connections to their loved ones (Klasen et al., Reference Klasen, Bhar, Ugalde and Hall2017) to support new possibilities in their lives (Levitt et al., Reference Levitt, Pomerville and Surace2016). Overall, these findings suggest client experience of PGDT share common therapeutic elements with other grief interventions, particularly the emphasis on therapeutic alliance and collaboration and importance of treatment personalisation.
With regard to implementation, clients noted that previous grief support was often non-directive, with fewer support strategies and less focused on grief. Clients emphasised that PGDT is a distinct therapeutic offering, particularly from other trauma-focused treatments which do not target PGD (Theme 5) and welcomed treatment choice.
A surprising and encouraging finding from the broader quantitative evaluation of PGDT pathway in NHS-TT (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025) that this qualitative study built on, was that clinical outcomes were superior in the routine care setting compared with previous clinical trials of PGDT (Shear et al., Reference Shear, Frank, Foa, Cherry, Reynolds and Maciejewski2001; Shear et al., Reference Shear, Frank, Houck and Reynolds2005; Shear et al., Reference Shear, Wang, Skritskaya, Duan, Mauro and Ghesquiere2014). In particular, rates of remission (scoring beneath clinical cut-offs) and response (>50% change in symptoms) on the primary grief outcome measure were greater in the NHS-TT implementation sample than the previous trial samples. This is an unusual pattern, as what is typically seen is a reduction in effect size when moving from controlled trial settings to real-world practice. As discussed in Goff et al. (Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025), this cannot easily be attributed to differences in client characteristics, as the previous PGDT trials and audit samples were broadly comparable in demographic and clinical characteristics.
While not an a priori aim of the present work (as the quantitative and qualitative evaluations ran concurrently before the quantitative outcomes were known), the present qualitative findings may nevertheless be able to shed light on these issues. As it was not a strictly monitored trial, therapists may have been more able to adapt and modify the protocol, and this tailoring was identified as helpful by a number of clients (Theme 3.2). Therapists were experienced with implementing depression, anxiety and PTSD protocols, and were able to weave these elements in as required whilst still following the grief protocol (‘flexibility within fidelity’). The revisiting sessions were experienced by clients as painful but transformative (Theme 4.4) and doing this work with an experienced therapist may have optimised this component of the treatment.
The study has a number of strengths and weaknesses. The study benefits from a large sample of clients. However, there are a number of limitations of note. Firstly, for pragmatic reasons, convenience sampling was used (inviting all participants who had completed the pathway to consider being interviewed, and interviewing those that responded until data saturation was reached). This is at risk of introducing self-selection bias (people who felt they had benefited from treatment may have been more willing to be interviewed) and means that the recruited sample may not fully represent the wider population who received PGDT in the service. A stronger approach would have been purposive sampling to achieve maximum variation in those interviewed in terms of engagement with, and benefit from, PGDT. All 11 participants (100%) in the interview sample had engaged well with PGDT and 10/11(91%) had shown reliable improvement. This compares with 83% engagement and 82% reliable improvement in the overall sample (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025), meaning those who did not engage and did not benefit from treatment are slightly under-represented in the interviews. Furthermore, the lack of demographic diversity and representation of clients who withdrew or did not benefit from therapy limits the generalisability of findings to those with diverse identities or experiences. Next, there were missing BGQ data for two clients (reflecting the fact that this was an optional measure that was not possible to deploy in an online format to patients, and relied on therapists to administer and enter it). For these two participants the link between qualitative experiences and clinical outcomes could not be examined, and may have differed from the remainder of the sample. Lastly, although an Expert by Experience provided feedback on the analysis findings, the clients and therapists interviewed did not provide feedback on the study themes and findings (other than co-author S.G., who was one of the therapists interviewed). Future research should consider incorporating this feedback, although the utility of member checking of this kind remains controversial in the literature and at times can be used tokenistically (cf. Birt et al., Reference Birt, Scott, Cavers, Campbell and Walter2016).
Nevertheless, this study has potentially important clinical and research implications. The intervention was viewed by clients as highly acceptable and effective. Together with the pilot evaluation (Goff et al., Reference Goff, Carson, Ladwa, Colletta, Topicu, Shear and Dunn2025), these findings suggest that PGDT is well-suited to the NHS-TT context and supports implementation of PGDT pathways. However, a multi-centre pragmatic randomised controlled trial of PGDT within an NHS-TT context is now required to establish effectiveness and support coordinated national commissioning and implementation across England. Such a trial should aim to recruit services with more diverse client populations and include a mixed-methods process evaluation to build upon present findings and explore whether any differences emerge in more heterogeneous samples.
Despite considerable ongoing debate around the pathologisation of grieving (Lund, Reference Lund2021), this project gives a voice and validates the experiences of those living with PGD. The growing evidence base indicates increasing risk factors and longstanding gaps in UK service provision (Harrop et al., Reference Harrop and Selman2022; Harrop et al., Reference Harrop, Mirra, Goss, Longo, Byrne, Farnell, Seddon and Selman2023). Thus, this research highlights the legitimacy of PGD as a psychological condition, particularly in cases with concurrent depression, anxiety, and PTSD, benefiting from tailored interventions.
In conclusion, the findings suggest that PGDT is viewed as an effective and acceptable intervention by individuals suffering from PGD. This study further substantiates the effectiveness of PGDT in addressing the multi-faceted and complex nature of PGD. With growing interest and clinical demand for effective PGD treatments, these findings provide meaningful insights into both the experience of delivering and receiving PGDT, which could support effective refinement and implementation of PGDT both within NHS-TT contexts and more broadly.
Key practice points
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(1) PGDT was perceived as an acceptable offering by clients receiving it.
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(2) PGDT was highlighted by clients as a good treatment offering that is better tailored to grief than existing NHS-TT offerings.
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(3) A flexible, tailored therapeutic approach was emphasised by clients as crucial for improving PGD outcomes.
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(4) A PGDT pathway was perceived to be implementable in existing NHS-TT service provision.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1754470X25100330
Data availability statement
No additional data are available.
Acknowledgements
With thanks to the PGDT therapists and participants who took part in the pilot evaluation, and support for the project from the Devon NHS-TT service and AccEPT Clinic. Co-author Sarah Goff is service lead overseeing the grief pathway evaluated here and was one of the therapists interviewed in the study. With special thanks to Dr Michael Hope, for his Expert by Experience input and support through the process of this research.
Author contributions
Maria King: conceptualization (equal), data curation (lead), investigation (lead), formal analysis (lead), data curation (lead), project administration (lead), writing- original draft (lead), writing- review & editing (equal); Taline Artinian: conceptualization (equal), formal analysis (equal), supervision (equal), writing- review & editing (equal); Asha Ladwa: data curation (supporting), writing -review & editing (equal); Sarah Goff: conceptualization (equal), writing- review & editing (equal); Megan Colletta: writing- review and editing (equal); Katherine Shear: conceptualization (equal), writing- review and editing (equal); Anke Karl: writing- review & editing (equal); Barnaby Dunn: conceptualization (equal), formal analysis (equal), supervision (equal), writing- review & editing (equal).
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors. However, B.D., A.L. and M.C.’s time was in part supported by funding to the AccEPT clinic from the Mental Health Mission (joint funded by the National Institute of Health Research and Office for Life Sciences). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health or Social Care.
Competing interests
S.G. (TALKWORKS Operational & Professional Lead) led the implementation of the PGDT pathway, as a Quality Improvement project for TALKWORKS Devon NHS-TT (the service that has been evaluated in this study). K.S. is the developer of PGDT and directs the Centre for Prolonged Grief at the University of Columbia.
Ethical standards
Ethical approval was granted by the UK National Research Ethics Service (REC reference: 23/SW/0080) and the Health Research Authority (IRAS ID: 328267). All clients provided full informed consent to participate in this study. This study has been conducted in accordance with the Ethical Principles of Psychologists and Code of Conduct as set out by the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and British Psychological Society. The conduct and reporting of this qualitative analysis is informed by the Standards for Reporting Qualitative Research (O’Brien et al., Reference O’Brien, Harris, Beckman, Reed and Cook2014; see Supplementary material SOM 2 for completed checklist) and the Consolidated Criteria for Reporting Qualitative Studies (Tong et al., Reference Tong, Sainsbury and Craig2007; see Supplementary material SOM 3 for completed checklist).
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