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Is Grief Therapy Justified?
Ironically, perhaps, this assumption represents at best a half-truth. Grief counseling has indeed proliferated, both in the formal venues of professional conferences, workshops, and publications, and in the countless institutional or community-based programs run by grief therapists, or operated on a mutual support basis by lay leaders. Moreover, scores of uncontrolled descriptive studies indicate that bereaved persons in these programs typically report reduced depressive, anxious, or general psychiatric symptomatology following their participation, reinforcing the impression that grief counseling is indeed effective in assisting with "recovery" from acute grieving.
However, only controlled studies in which bereaved individuals are randomly assigned to treatment and control conditions can yield a clear verdict on the effectiveness of grief therapy. Uncontrolled studies are at best suggestive, as acute grief could simply remit with the passage of time, as a function of "curative factors" (e.g., social support) in the natural environment or as a result of the bereaved person's own coping efforts. Indeed, when controlled studies of professional interventions are analyzed (as in Rose and Bisson's, 1998, review of debriefing interventions cited by Davis et al., in press), results are often equivocal, with different studies suggesting positive, negative, and "no difference" conclusions. Such results make it essential to conduct a comprehensive review of all controlled outcome studies of grief counseling to reach confident conclusions about whether grief therapy is indeed effective, and if so, for whom.
My colleagues--Barry Fortner, Adam Anderson, Jeff Berman--and I have just completed such a review (Fortner & Neimeyer, 1999).(n1) In undertaking this project, we were struck by the extent to which recent reviewers of this literature (e.g., Kato & Mann, 1999) analyzed only a small subset of the available studies, and even then, relied primarily on impressionistic evaluations of outcome, supplemented by relatively global application of quantitative review methods. Others (Allumbaugh & Hoyt, 1999) offered more detailed quantitative reviews of the published and unpublished literature but included numerous uncontrolled one-group studies that could have inflated estimates of the effectiveness of the therapies studied. The result was significant discrepancy from one review to the next regarding the efficacy of psychosocial interventions for the bereaved. To remedy these and other shortcomings of previous reviews, my colleagues and I located all scientifically adequate outcome investigations of grief therapy published between 1975 (when the first such research appeared) and 1998, a total of 23 separate studies reported in 28 different papers. As criteria for inclusion, all had to focus on bereaved persons mourning the death of a loved one, who received some form of psychosocial intervention (psychotherapy, counseling, or facilitated group support), and who were randomly assigned to a treatment or control condition. The over 1,600 participants in these studies had experienced a wide range of losses--of spouses, children, and other family members--who had died from a broad spectrum of causes, both sudden and protracted. Professional therapists provided therapy in 19 of these studies, and nonprofessionals conducted the remainder. Finally, it was notable that the majority of studies assessed outcome on generic measures of health, depression, anxiety, or psychiatric distress, while only a few attempted to measure grief per se, and then typically using idiosyncratic or unvalidated measures.
We assessed the efficacy of grief therapy using two statistics, one of which has been widely used in meta-analyses conducted over the last 20 years and one of which represents a recent innovation in quantitative review procedures. The first of these was Cohen's d, which reflects the posttest difference between treated and untreated groups across a range of outcome measures--a straightforward measure of the degree of benefit associated with participation in therapy (Cohen, 1997). The second, more novel procedure allowed us to estimate treatment-induced deterioration, which represents the proportion of participants who are worse off after treatment than they would have been if they had been assigned to the control group.(n2) It is important to emphasize that this latter measure did not reflect absolute deterioration--the case of an individual functioning more poorly after therapy than before--because the therapy could still be deemed helpful in this case if the same person would have been even more symptomatic with no treatment. Likewise, therapy clients could actually make some gains but still fall short of where they would be if the treatment held them back relative to where they would be if untreated. Thus, we were interested in treatment-induced deterioration, defined as all instances in which therapy recipients theoretically would have fared better if left alone, irrespective of the absolute direction of change they showed over the course of the study.
Analyzing the 23 randomized controlled studies using these metrics produced some interesting results. To begin with, we found that the mean effect size of. 13 was positive, and reliably different than zero, reflecting the superiority of outcomes for treated relative to untreated persons. However, the effect size was also quite small in absolute terms, when compared with the much more substantial effects associated with psychotherapy for depression and for psychological disorders more generally. Stated in other terms, the average participant in grief therapy was better off than only 55% of bereaved persons who received no treatment at all--hardly an impressive demonstration of the efficacy of grief counseling.
The analysis for treatment-induced deterioration was perhaps more sobering still. When we computed this statistic, we discovered that nearly 38% of recipients of grief counseling theoretically would have fared better if assigned to the no-treatment condition; in strong contrast, only 5% of clients in a broad range of psychotherapies for other problems showed such deterioration (Anderson, 1999). Thus, not only is the tangible benefit of grief therapy small, but its risk of producing iatrogenic worsening of problems is unacceptably high--a troubling pattern that is unique among typically effective and safe psychosocial interventions.
What could account for these disconcerting findings? Unfortunately, simple explanations focusing on the intractability of loss, or the necessity to engage in distressing "grief work" prior to reestablishing an emotional equilibrium, however valid, fail to account for the differential deterioration of treated versus untreated clients. Moreover, spontaneous improvement of treated and untreated subjects alike seems implausible, given the findings of Allumbaugh and Hoyt (1999) suggesting essentially no improvement in the latter category over the brief periods associated with the average treatment study. The brevity of the therapies provided (whose mean number of sessions was 7) might also be argued to mitigate the effectiveness of these interventions, as substantial grief can persist for a period of years. However, such an argument is weakened by the variable length of therapy represented by these two dozen studies, and our finding that effect size was uncorrelated with length of treatment. Nor did categorical distinctions associated with the therapies or therapists account for the poor showing of these therapies, as outcome was also unrelated to type of treatment (individual vs. family vs. group), therapeutic approach, or level of training of therapists (professional vs. nonprofessional). What, then, could explain the limited use and high risk of grief counseling?
In pursuing answers to these questions, we found some promising leads in the
differential responses of different clients to the interventions offered. For
example, clients varied considerably in the length of time between their loss
and enrollment in bereavement programs (M--6 mos.), with some being offered
services immediately after the death had occurred, and others being approached
many years later. Interestingly, better outcomes were obtained for clients
who were more distant from the death (r = .5 between treatment effect and weeks
of bereavement). Likewise, the deterioration effect was strongly correlated
with client age (r = -.7), suggesting that younger clients fared better than
older ones in such therapies. Perhaps most interesting, however, was the result
of a follow-up analysis in which we discriminated between outcomes in those
5 studies offering treatment for persons who were traumatically bereaved (e.g.,
through violent, sudden, or untimely death, or whose grief was more chronic)
and those that focused on "normal" bereavement reactions. Here,
the results were especially clear: Counseling for normal grievers had essentially
no measurable positive effect on any variable (d = .06), whereas the subset
of studies offering therapy for traumatic grief showed a reliable positive
effect (d = .38). Equally heartening was the finding that deterioration effects
were substantially lower for traumatized clients (17%) than for normal or unselected
samples, for whom nearly one in two clients suffered as a result of treatment.
Together, these findings point toward an intriguing and consistent conclusion:
That grief therapy is appropriately offered to mourners experiencing protracted,
traumatic, or complicated grief reactions. Conversely, existing evidence from
scientifically credible controlled outcome trials suggests that grief therapy
for normal bereavement is difficult to justify.
Reflection Exercise #5
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