Therapists' responses to grief at the initial sessions: A qual-itative observational study

This exploratory qualitative study aimed to examine how mental health profession-als emotionally and clinically respond to a patient presenting symptoms of Pro-longed Grief Disorder (PGD), a diagnosis recently included in the DSM-5-TR and ICD-11. The purpose was to investigate therapists' emotional experiences, their in-session responses, and their diagnostic reasoning when faced with a complex grief presentation, using a behavioral observation-based approach. In the first phase, par-ticipants completed a demographic and professional background form via Qualtrics. In the second phase, they participated in an online standardized simulated therapy session with one of two trained psychologists portraying a bereaved patient. In the third phase, therapists were interviewed by the primary researcher immediately fol-lowing the session, using a semi-structured format to explore their in-session experi-ences and diagnostic impressions. Reflexive thematic analysis identified twenty recurring therapist themes, grouped under four overarching categories: (1) Relational Holding and Narrative Formation, (2) Premature Directive Interventions Lacking Emotional Grounding, (3) Thera-pists' Defensive Self-Regulation, and (4) Therapists' Functional Collapse into Primi-tive Defenses. These categories reflected different relational and emotional stances adopted in response to the patient's grief. Diagnostic impressions varied considerably. Only 21.4% of participants labeled the case as PGD. The largest proportion 25% described it as a normal grief process, while others proposed major depression or a comorbid formulation. These findings highlight persistent diagnostic ambiguity and suggest that therapists may hesitate to pathologize grief. Emotional responses ranged from expected sadness, anxiety, and unease to feelings of identification, familiarity, empathy, and the desire to help. Keywords: Prolonged Grief Disorder, in-session responses, reflective thematic anal-ysis, therapist subjectivity, diagnostic ambiguity