Papers by M. Katherine Shear
Background: Prolonged grief disorder (PGD) is a newly recognized mental disorder characterized by... more Background: Prolonged grief disorder (PGD) is a newly recognized mental disorder characterized by pervasive intense grief that persists longer than cultural or social expectations and interferes with functioning. The COVID-19 epidemic has resulted in increased rates of PGD, and few clinicians feel confident in treating this condition. PGD therapy (PGDT) is a simple, short-term, and evidence-based treatment developed in tandem with the validation of the PGD diagnosis. To facilitate the dissemination of PGDT training, we developed a web-based therapist tutorial that includes didactic training on PGDT concepts and principles as well as web-based multimedia patient scenarios and examples of clinical implementation of PGDT. We aimed to evaluate user satisfaction with the tutorial and whether the tutorial increased trainees' knowledge of PGDT principles and procedures. Moreover, we included a small number of pilot questions to evaluate the PGDT-related clinical skills. Methods: This study evaluated tutorial learning using a pre-and poststudy design. Participants were recruited from professional organization mailing lists, announcements to graduates of the Columbia School of Social Work, and through word of mouth. After signing consent, participants completed a brief demographic survey, a 55-item multiple-choice prestudy test on the concepts and principles of PGD and PGDT covered in the tutorial, and a 4-item pilot web-based prestudy test to gauge PGD clinical implementation skills. The link to the course content was then activated, and participants were given 8 weeks to complete the 11-module tutorial containing information, web-based exercises, simulated patient and video examples, and self-tests. Results: Overall, 406 clinicians signed consent, and 236 (58.1%) started the tutorial. Of these, 83.1% (196/236) completed all 11 modules. Trainee scores on our PDGT assessment improved substantially from pretraining to the postmodule assessment, with the total number of correct answers increasing from a mean of 29 (SD 5.5; 52.7% correct) to 36.7 (SD 5.2; 66.7% correct; t 195 =18.93; P<.001). In addition, the trainee's implementation scores on 4 clinical vignettes increased from 2.6 (SD 0.7) correct out of 4 to 3.1 (SD 0.4) out of 4 (t 188 =7.02; P<.001). Effect sizes (Cohen d) were 1.44 (95% CI 1.23-1.65) for PDGT assessment and 1.06 (95% CI 0.84-1.29) for implementation. Trainees found the tutorial interesting, enjoyable, clearly presented, and useful for professional development. They endorsed a mean score of 3.7 (SD 0.47) on a 1 to 4 scale of agreement with recommending the course to others and feeling satisfied with the tutorial, and a mean of 3.3 (SD 0.57) with feeling able to apply the skills with clients. This pilot study provides support for the usefulness of this web-based training for teaching clinicians how to administer PGDT. The addition of patient scenarios for clinical implementation strategies holds promise for increasing the effectiveness of PGDT training and other evidence-based treatments.
Comprehensive Psychiatry, Sep 1, 2007
Background: Complicated grief (CG), variously called pathological or traumatic grief, is a debili... more Background: Complicated grief (CG), variously called pathological or traumatic grief, is a debilitating syndrome that is not currently included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) nomenclature. One issue that remains under debate is whether this condition can be clearly distinguished from other psychiatric disorders, such as major depression and posttraumatic stress disorder, with which CG frequently coexists. Methods: Using a structured clinical interview for CG and the Structured Clinical Interview for DSM-IV, trained experienced raters conducted careful diagnostic assessments of individuals seeking treatment of bereavement-related distress. All study participants met criteria for a current CG syndrome. Liberal criteria were used to diagnose DSM-IV disorders, making no attempt to decide if symptoms could be explained by grief. Results: Of 206 who met the criteria for CG, 25% had no evidence of a current DSM-IV Axis I disorder. When present, psychiatric comorbidity was associated with significantly greater severity of grief; however, even after adjustment for the presence of comorbidity, severity of CG symptoms was associated with greater work and social impairment. Limitations: It is likely that our study underestimated the rate of CG without comorbidity because fewer DSM diagnoses would have been made if a judgment about grief had been taken into consideration. Conclusions: Our data provide further support for the need to identify CG as a psychiatric disorder.
Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, Mar 1, 2019
The intense loss processing that characterizes grieving may help people adapt to the loss. Howeve... more The intense loss processing that characterizes grieving may help people adapt to the loss. However, empirical studies show that more conscious loss-related thinking and greater reactivity to reminders of the deceased correspond to poorer adaptation. These findings raise the possibility that loss processing that is unconscious rather than conscious and self-generated rather than reactive may facilitate adaptation. Here, we used machine-learning to detect an fMRI signature of self-generated unconscious loss processing, which, we hypothesized to correlate with lower grief-severity. Methods: 29 subjects bereaved within the past 14-months participated. Participants performed a modified-Stroop-fMRI-task using deceased-related words. A machine-learning-regression, trained on Stroop-fMRI data, learned a neural pattern for deceased-related-selective-attention (d-SA), the allocation of attention to the deceased. Expression of this pattern was tracked during a subsequent sustained-attention-fMRI-task interspersed with deceased-related thought probes (SART-PROBES). d-SA pattern expression during SART-PROBES blocks without reported thoughts of
Journal of Consulting and Clinical Psychology, 2013
Although associations with outcome have been inconsistent, therapist adherence and competence con... more Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective-(a) statistically demonstrate between-and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method-Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each
Bereavement Care, Dec 1, 2010
Many people resist the notion that grief could be considered a mental disorder, but the depth of ... more Many people resist the notion that grief could be considered a mental disorder, but the depth of some bereaved people's distress can mean they experience very great difficulty in progressing through the natural healing process. This article outlines an attachment theory perspective on the concept of complicated grief and a research-validated treatment (complicated grief therapy) that has been found to be effective in helping people address impediments that keep them from integrating the new reality of their lives. complicated grief; attachment theory; complicated grief treatment; dual process model; prolonged grief disorder 'The assertion that, because grief will be experienced by most of us sooner or later, it cannot be said to be an illness is not valid… If a bruise or a broken arm, the consequence of physical injury is within the realm of pathology, why not grief, the consequence of a psychological trauma?' (Parkes, 1996, p5) Most people are understandably wary of labeling grief as an illness, given the complex social and political issues that currently surround medicine. However, notwithstanding justifiable reticence, Parkes' argument has merit. People who are otherwise healthy can experience acute grief following the loss of a much loved person, and this grief can be very often more painful and disruptive than many physical illnesses. Bereavement can temporarily render a person a mere shadow of their former self, disoriented and besieged by intensely painful emotions. The bereaved person may feel intense yearning for the lost person; they can become so preoccupied with thoughts and memories of them that they find it difficult to care about anything else or to engage in ordinary activities, separating them from the rest of the world. The suffering of bereaved people often confuses clinicians. On the one hand, it seems inhumane to leave such anguish untreated. On the other hand, if we regard grief as a normal human experience, this suggests it is not an appropriate focus for clinical treatment. Which is correct? Should we treat bereaved people or leave them to heal naturally? If we do provide treatment, when, why and how should we intervene? What outcome should we seek? The purpose of this paper is to describe how our clinical research group has answered these questions with respect to complicated grief-a condition we do treat. The paper covers principles, strategies and techniques of complicated grief treatment and reports the results of a study supporting its effectiveness. The treatment approach rests on a conceptualisation of grief informed by attachment theory.
Acknowledgements Columbia University’s School of Social Work, Center for Teaching and Learning, a... more Acknowledgements Columbia University’s School of Social Work, Center for Teaching and Learning, and Office of the Provost Hong Kyung Anna Suh, Kevin Ram, Colleen Gribbin Bloom, Bonnie Gorscak, Jill Harrington, Stephanie Ogden, Jessica Rowe, Celine Zaphiratos, Jon Hanford, Vincent Aliberto, Andre Laboy, Lucy Appert, Michael Deleon, Steven Schinke, John McDonald, Starsha Jordan, Irv Garfinkel, Katherine S Rochmat, and the students of the Fall 2018 Intro to Grief Therapy course Katherine Shear, Marion E. Kenworthy Professor of Psychiatry in Social Work, Kristin Garay, Matthea Marquart, School of Social Work
Journal of Loss and Trauma, 2016
Avoidance behavior (engaging in any actions to avoid or escape particular thoughts or feelings) i... more Avoidance behavior (engaging in any actions to avoid or escape particular thoughts or feelings) is a universal response to emotionally charged-situations that is most commonly associated with anxiety or fear. However, avoidance behaviors also are commonly employed to regulate a variety of distressing emotions, and therefore are present across a wide range of emotionally-charged situations. For instance, after a meaningful loss, bereaved individuals often attempt to manage the strong emotional pain associated with death, of a loved one either through deliberate suppression of painful thoughts and emotions associated with the loss, or through avoidance of situations, places, and objects related to the deceased (Boelen, van den Bout et al. 2006. For example, a mother who lost her son might avoid places he used to go (i.e. his school or bedroom), seeing his friends, or participating in activities that they may have enjoyed together. Avoidance is generally considered an adaptive response to loss, and an integral component of the initial, acute grief response. This avoidance may be of both situations and/or stimuli that are reminders of the loss and avoidance of emotions about the loss. Individuals with CG may use distraction or transitive shifts in awareness to non-loss related content in order to lessen the emotional impact of the loss . Avoidance (both emotional and situational) initially allows some respite from intense pain in order for the individual to process the loss and restore a satisfying ongoing life (Bonanno et al.,
The Journal of psychotherapy practice and research, 2001
This is a complete report of an open trial of manualized psychodynamic psychotherapy for treatmen... more This is a complete report of an open trial of manualized psychodynamic psychotherapy for treatment of panic disorder, Panic-Focused Psychodynamic Psychotherapy (PFPP). Twenty-one patients with PD were entered into a trial of twice-weekly, 24-session treatment. Sixteen of 21 experienced remission of panic and agoraphobia. Treatment completers with depression also experienced remission of depression. Improvements in symptoms and in quality of life were substantial and consistent across all measured areas. Symptomatic gains were maintained over 6 months. This report was prepared specifically to describe 6-month follow-up on these patients. Psychodynamic psychotherapy appears to be a promising nonpharmacological treatment for panic disorder.
Psychiatric services (Washington, D.C.), 1999
The charts of patients who received an initial assessment at a rural mental health center were re... more The charts of patients who received an initial assessment at a rural mental health center were reviewed to identify patient, system, and clinical characteristics that predicted return to the center for at least one treatment visit in the following three months. Among 112 patients, the overall rate of return was 46 percent. Patients who were seen for assessment within one week of their initial request for services were significantly more likely to return, as were those who had lower scores on the Global Assessment of Functioning scale. Patients referred for assessment by agencies of social control were the least likely to return for treatment.
Psychosomatic Medicine, 2003
Psychoanalytic Inquiry, 1991
... Psychopharmacologists have returned to a view of panic disorder as a different form of ... le... more ... Psychopharmacologists have returned to a view of panic disorder as a different form of ... led to rapid alleviation of panic symptoms in many patients through psychopharmacological intervention. ... The cognitive-behavioral theory, however, also does not fully address the issues of ...
Journal of General Internal Medicine, 2005
BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by ... more BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial. To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses.
Journal of Consulting and Clinical Psychology, 2013
Although associations with outcome have been inconsistent, therapist adherence and competence con... more Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective-(a) statistically demonstrate between-and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method-Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each
Journal of Consulting and Clinical Psychology, 2007
Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic... more Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic disorder with mild or no agoraphobia, but little is known about the mechanism through which these treatments work. The present study examined some of the criteria for cognitive mediation of treatment change in CBT alone, imipramine alone, CBT plus imipramine, and CBT plus placebo. Ninety-one individuals who received 1 of these interventions were assessed before and after acute treatment, and after a 6-month maintenance period. Multilevel moderated mediation analyses provided preliminary support for the notion that changes in panic-related cognitions mediate changes in panic severity only in treatments that include CBT.
The Journal of Clinical Psychiatry, 2007
International Journal of Methods in Psychiatric Research, 2000
In this study we evaluated the psychometric properties of the Structured Clinical Interview for t... more In this study we evaluated the psychometric properties of the Structured Clinical Interview for the Anorexic‐Bulimic Spectrum (SCI‐ABS), including internal consistency, concurrent validity, discriminant validity and test–retest reliability. We also determine acceptability and feasibility of administration of the interview. The SCI‐ABS was designed to assess typical and atypical symptoms, behaviours and temperament traits pertaining to eating disorders. The interview included 134 items grouped into nine domains, four of which were divided into subdomains.Data were collected from 372 subjects: 55 psychiatric patients with any eating disorder according to DSM‐IV criteria, 118 university students, 141 subjects working out in a gym, and 65 obstetrical patients. Concurrent validity of the instrument was assessed against the Eating Attitude Test (EAT) and the Eating Disorder Inventory (EDI). Thirty‐five subjects were also recruited to study the test–retest reliability and 25 women with any...
Depression and Anxiety, 2001
Bereavement Care, 2010
Instruction Manual Used in NIMH Grants 1,2 Complicated Grief Treatment "By following the instruct... more Instruction Manual Used in NIMH Grants 1,2 Complicated Grief Treatment "By following the instructions in this manual and using other training supports as needed, you can learn to administer a simple, highly effective treatment that can change the lives of people caught in a seemingly endless cycle of grief." -M. Katherine Shear, M.D.
American Journal of Psychiatry, 2008
, it has not been shown to be more effective than medication in studies of patients with chronic ... more , it has not been shown to be more effective than medication in studies of patients with chronic depression. In addition, most, if not all, studies of IPT have been conducted in outpatient settings. This study is remarkable in that it shows evidence of significantly greater gains in chronically depressed inpatients who received IPT plus medication than in patients who received clinical management and medication. In addition, the greater treatment gains were maintained over a 1-year period. This is an impressive showing for the use of adapted IPT for chronically depressed patients in inpatient settings. The authors raise some interesting points about the different responses of chronically depressed patients in this study versus earlier studies. They note that most previous trials of psychotherapy for chronic depression included only dysthymic patients, whereas this study included predominantly severely depressed patients. Thus, the patient populations are different. In addition, previous studies used standard IPT, whereas this study adapted the treatment for this population, using a combination of individual and group treatment. Most patients in this study also continued medication and/or psychotherapy after hospital discharge, whereas previous studies used a short-term model of treatment. As the authors note, one reason for the differential response may be that therapists spent a good deal more time with IPT patients than the patients who received clinical management. IPT patients received treatment that was the length of a full psychotherapy session, whereas the clinical management patients saw their therapists for only 15 to 20 minutes. This means that clinical management patients received only one-half or one-third the amount of time with their clinicians as those being treated with IPT. Although this study provides useful information, it is doubtful that IPT will be added to many inpatient regimens. An important caveat is that this study was conducted in Germany, a country with a health care system that is quite different from that in the United States. Given that many inpatients in the United States spend only a few days in the hospital, it is unlikely that many units would have the time or the resources to implement a program with as intensive a psychotherapy program as this study recommends.
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Papers by M. Katherine Shear