Psychology Today Blogs - The Journey Ahead

Is “grief counseling” helpful or harmful to the bereaved?

J. Worth Kilcrease, LPC, FT — Fri, 09 May 2008 19:13:52 -0700

Last week, the Association for Death Education and Counseling (ADEC) held its 30th Annual Conference in Montreal, Canada. There were several important presentations, some of which I will be writing about later. However, today I want to concentrate on one session that is relevant to a topic that has been in the popular press and on the television show Boston Legal: Is “grief counseling” helpful or harmful to the bereaved?

After years of research, there is little reason to doubt that psychotherapy is an effective way to help most people who are experiencing distress. Both professional journals and the mass media have reported that despite the theoretical approach of the clinician or who is receiving the therapy - individuals, family, or groups - clients are in significantly better shape after therapy than those who do not take advantage of it.

For the subset of psychotherapy known as grief or bereavement counseling, however, the effectiveness of therapy is not as well established. There are three reasons for this lack of clarity:

Contrary to other therapeutic areas which aim to treat and assuage preexisting, specific disorders and problems with living, bereavement counseling is most often practiced as a preventive treatment. Its goal is to diminish a client’s probability of suffering future psychological or physical problems. Unlike non-bereavement therapy, there are no easy means to examine the impact of treatment on a pre- and post-treatment basis.
Most bereaved people have a tendency to improve in their adaptation to the loss without any professional assistance. Only 10-15% of those whose loved one has died experience suffering and grief so intense and for so long that they develop psychological and physical debilitation, sometimes to the point of being fatal.
Many studies have failed to distinguish between the three broad categories of bereavement interventions as delineated by the Institute of Medicine (IOM): universal, selective, and indicated.

Universal interventions are those that focus on anyone who is bereaved without considering individual death-related risk factors or preexisting functioning.
Selective interventions are oriented to those whose loss has the potential for causing high distress such as those whose child died violently, suicide survivors, etc.
The third category, indicated interventions, addresses those who present significant problems adapting to the death. These problems could include normally recognized psychological symptoms such as depression or other clinically important complications such as guilt, loss-related intrusions, rage, etc. It is also important to note that the complicated grief these mourners suffer will not diminish just because of the passage of time nor can it be simply reduced to common psychological disorders such as depression and PTSD.

Because of these variables, the reports of how helpful counseling is for the bereaved have ranged from favorable to neutral to harmful.

At the ADEC conference, Joseph Currier and Robert Neimeyer presented the findings of their analysis of the existing research and tried to make some sense out of the disparate results. They, along with Jeffrey Berman, conducted a comprehensive meta-analysis of 61 published, controlled research studies on the efficacy of bereavement counseling. Besides examining how effective counseling can be, the researchers also attempted to determine if timing for starting therapy; the method of recruitment; the mode of death; or the bereaved person’s sex, age, or relationship to the deceased had any bearing on the results.

Without going into the details of the study, let me summarize what they found. Their analysis showed that general bereavement counseling has a slightly helpful effect that continues for only a short time after the intervention ends. These findings are similar to those for generically applied trauma interventions. However, when Currier, Neimeyer, and Berman delved more deeply into the data, they made some interesting discoveries.

Interventions that addressed the universal population did not produce any statistically better results than those that occur from the mere passage of time. Most people have the personal resiliency and available societal and familial support systems to help them adapt to the loss, whether they receive counseling or not.
For those who qualify for selective interventions, counseling did provide more benefit, but it was short-lived and not statistically significant later.
However, if the proper steps were undertaken to assess if the client was having specific problems in adapting to the loss and if any of these problems were subsequently addressed, i.e., indicated interventions, the effects of the counseling were the same as in other areas of psychotherapy.

It is also noteworthy that Currier, Neimeyer, and Berman found that except for the method of recruitment, no relationship existed between the other possible factors (the sex or age of the bereaved, timing of therapy, etc.) and successful therapy. The only effect that the method of recruitment had was with clients who were either self and/or clinically referred. Referred clients experienced better outcomes than those who entered therapy as the result of aggressive outreach programs.

So, the answer to the question “Is ‘grief counseling’ helpful or harmful to the bereaved?” is “It depends.” As Neimeyer said at the conference, counseling helps, unless it doesn’t. In other words, for those bereaved individuals needing indicated interventions, the higher the level of bereavement-related distress, the greater the benefit they will receive from bereavement therapy. To read the entire paper, click on The Effectiveness of Psychotherapeutic Interventions for the Bereaved: A Comprehensive Quantitative Review.

Time Heals All Wounds, or Does It?

J. Worth Kilcrease, LPC, FT — Thu, 24 Apr 2008 20:12:59 -0700

As a counselor who specializes in end-of-life and bereavement matters, I often hear of people giving bereaved people advice similar to “you just need some time, after all ‘time heals all wounds.’” It is as if these well-meaning people are saying: “Just sit back and in time you’ll no longer have the sadness, anguish, yearning, guilt, anger, and fear you’re feeling now. They’ll fade away, and you’ll be fine.” Wow! What an interesting concept! But wait a minute, that approach to grieving raises a couple of questions. First, how long is “some time” - two months, one year, two years, five years? The second question is why doesn’t this apply to the rest of our lives? After all, we have to look for a new job, search for the right house, study to get through school. Even if we want to win the lottery, we still have to buy the ticket. We have to take the initiative to do something to cause something else to happen. Is grief different? Can it really be true that time alone is enough for grief to go away? I don’t think so and let me give you an example why.

Last year, a bright, highly-educated, articulate young woman came into my office six years after her father had suddenly died. My new client told me she was working two jobs, one of which was heading up a new company she had started. She described how she had found it very difficult to talk, or even think, about her father without bursting into tears. To keep herself “under control,” she kept herself frantically busy. She threw herself into her work, taking on tasks others wouldn’t do, answering email and writing proposals until late at night, and traveling on most weekends. At home, she spent hours cleaning and straightening up her apartment so it looked like a picture out of a magazine. One thing she did that really irritated her new fiancee was that she spent hours folding and re-folding towels and then aligning and realigning them in the linen closet until they were just right. She was doing whatever she could to distract herself from acknowledging what she already knew - her father had died. She was running from her grief.

She finally realized she had to do something because she couldn’t continue this way after she married and had children. Her first attempt at addressing her situation was to attend a Loss of Parent bereavement support group. However, she could go only once. As she later told me, she was embarrassed that she was in the same place in her mourning as others whose parent had died only six months earlier. It was as if her mourning had gone no further from where it was 5.5 years ago. She was stuck, and no more time would have eased or erased her grief. Time had done nothing for her; time had NOT been her friend.

After six months of counseling she worked through what she had been running from for over 5 years and found peace with her father’s death. Her frantic behaviors have ceased and now, she is a fully functioning young woman with plans for getting married next year.

The point here, though, is that time does NOT heal all wounds. A more apt saying is “IT’S WHAT YOU DO WITH THE TIME THAT HEALS.” Like any other aspect of life, mourning is an active, working process, not a passive one.

Stages of Grief - Time For a New Model

J. Worth Kilcrease, LPC, FT — Sun, 20 Apr 2008 20:31:07 -0700

Again, it appeared in print - the stages of grief. This time it was in an Austin American Statesman article about a soon-to-be closed bar near the University of Texas campus. A young man who is a patron of the bar stated that he was going through the seven stages of grief, but was stuck on anger. Ignoring for now the possibility of mourning over the closing of a bar, I wonder why the myth that mourning (grieving) happens in stages or phases is still so prevalent in our society. After all, there are other, more descriptive models that better describe the process. So what’s wrong with stage-based models of mourning? There are several.

There is a multitude of stage theories, so which one is the correct one? There are theories involving three, four, five, six, seven, ten, and twelve different stages. The most famous model is a misapplication of Elizabeth Kubler-Ross’s five stages of coping with dying: denial, anger, bargaining, depression, and acceptance (DABDA for short). This model for mourning is the most egregious one since it is a totally erroneous application of her work.
Regardless of which one you chose, each stage theory attempts to portray a complex process involving the emotional, behavioral, cognitive, spiritual, and social facets of a person with a few simplistic terms. While simplicity can help describe something, it can also be very misleading.
There is no empirical proof that any stage-based model describes everyone’s bereavement experience. The models have been based on observations of select populations and not, until recently, subjected to empirical study. In the February 2007 edition of the Journal of the American Medical Association (Vol. 297, No. 7), Maciejewski, Zhang, Block, and Prigerson reported on their study that apparently confirmed a five-stage model of mourning adapted from Kubler-Ross’s model. However, many critical reviews regarding the researchers’ methodology, including their highly selected study sample, cast serious doubt on the validity of their conclusions.
Stages imply that mourning is passive. A good analogy is a car wash. First is the “vacuuming the floor” stage, followed by the “clean the bugs off the windshield” stage, followed by the “wash, and rinse” stage, followed by the last stage - the “drying off” stage. The car doesn’t do anything but be there, and everything happens to it so it comes out of the process bright and shiny clean. Mourning is not a passive process like a car wash; it is a highly active one.
Stage models create expectations of what mourning is supposed to be like. To me, this is a major shortcoming because of the potentially detrimental effect on the bereaved. A widely published list of stages sets people up to expect certain reactions after the death of a loved one. When those expectations don’t happen or don’t happen in the “correct” order, the bereaved individuals can think there is something wrong with them. I have had several clients come to me stating they haven’t experienced one stage or another, and they're scared they're not grieving the way they should. Once I explained to them that stages are an artificial construct, they were definitely relieved. There are typically enough shouldas, wouldas, and couldas for a bereaved person to work through without adding whether he/she has adequately encountered all the stages of grieving or if the stages have occurred in the proper sequence.

I believe it is about time we quit trying to distill the interpersonal and intrapersonal complexities of mourning into a simplistic set of dogmatic steps. Mourning is a highly individualistic process based on many factors in the bereaved person’s life. It is a process for finding meaning in a distressing time of loss, creating a new relationship with the deceased, reintegrating the deceased into the bereaved person’s being, and learning how to live in the world under a new set of conditions and assumptions. It is NOT a checklist.

Life Ends at 150, or Later?

J. Worth Kilcrease, LPC, FT — Mon, 07 Apr 2008 13:48:29 -0700

On the evening of April 1, Barbara Walters hosted an ABC News Special called Live to 150, Can You Do It? The show included interviews of leading researchers looking for ways to prolong life. A couple of drug researchers from Boston stated they believe that resveratrol, a substance in red wine, can prevent common aging diseases such as Alzheimer’s Disease and diabetes. Coupling this with new technology for growing organs from stem cells like spare parts of a car, we might have found the modern day version of the “Fountain of Youth” that Juan Ponce de Leon was supposedly looking for.

While watching the special, my question was “Why would someone want to live to be 150?” In 2002, the average life expectancy for a newborn in the United States was 77 years. If these researchers are correct, that life span could double. The follow-up question is “Will more years be added on as one becomes elderly or will they be spread out over an entire life?” If they’re added as one becomes elderly that would imply that a person will get new spare parts as old ones wear out. People will become physically stuck in their earliest age of disintegration while continuing to age psychologically, spiritually, and mentally.

The other possibility is that the added 75 years are spread over a person’s life. Could adolescence last 20 years? With replacement parts, would a woman’s childbearing years last 70 years? Would menopause take twice as long? Do most people REALLY want to spend twice as long at each stage of their life as they do now? I doubt it.

Erik Erickson proposed that humans go through stages of development. The last one is late adulthood/elderly when psychological conflicts revolve around integrity vs. despair. Those who have integrity feel complete, content, and satisfied with their lives, and are more serene as they face the end. Their later years can be the best ever, as exemplified by the centenarians on the show. Those who have despair, however, feel they have made too many wrong decisions and have no remaining opportunities to change their lives. Bitterness, defeat, and hopelessness consume them, and they find it very hard to accept death.

Modern technology allows, and sometimes forces, people to live longer. Advances in medicine blur the line between living and dying. The addition of spare body parts and youth-maintaining miracle drugs blurs that line even more. How will someone worn out emotionally and spiritually, even if not physically, be able to look forward to when he/she can “let go” and leave this world?

In our search for immortality, there is little recognition that death has an important role: it is a part of life; life needs death. We cannot relieve our existential anxiety of death by living longer. The anxiety will only last longer. Death will still happen. Our quest should be to create more integrity in our lives so when we face our inevitable death, its sting is gone.

I’d like to know what you think about living to 150. Leave me a comment below.