A synthesis of psychological interventions for the bereaved

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A SYNTHESIS OF PSYCHOLOGICAL INTERVENTIONS FOR THE BEREAVED

Pamela M. Kato and Traci Mann

Stanford University

ABSTRACT.

Several interventions have been implemented to address the adverse psychologicaland physical consequences associated with bereavement. In this review, we summarize four majortheories of bereavement, present a qualitative review of bereavement intervention studies, and as-sess the overall effectiveness of bereavement intervention studies in a quantitative meta-analysis.Summaries of the theories are drawn from published theoretical works. The qualitative and quan-titative reviews were based on searches of Medline, PsychINFO, and Dissertation Abstracts Inter-national databases using the keywords “bereaved” and “bereavement.” Overall, the interventionswere largely methodologically flawed, rarely specified what theory of bereavement they were testing,and showed surprisingly weak effect sizes. Possible interpretations for the small effect sizes are dis-cussed, and future directions are outlined. © 1999 Elsevier Science Ltd

SUFFERING THE loss of a loved one strongly impacts the psychological and physicalhealth functioning of the bereaved. Psychological reactions to loss are characterizedby varying levels of negative emotions such as depression, anxiety, despair, numbness,and disbelief (Bowlby, 1980). The physical health consequences of bereavement in-clude compromised immune function (Irwin, Daniels, & Weiner, 1987), increasedhospitalizations and surgeries (Glick, Weiss, & Parkes, 1974), and increased mortalityrates (Osterweis, Solomon, & Green, 1984; Young, Benjamin, & Wallis, 1963; see Stroebe& Stroebe, 1993, for a review). The adverse psychological and physical health outcomesassociated with bereavement make intervention with people who have experienced aloss an important public health matter.

The two authors made equal contributions to this article. Order of authorship was therefore de-termined alphabetically. Pamela M. Kato (now at The Children’s Health Council, Palo Alto,CA) and Traci Mann (now in the UCLA Department of Psychology) were in the Department ofPsychology, Stanford University, Stanford, CA at the time of this project.This project was supported in part by a National Research Service Award from the Public HealthService. The authors would like to acknowledge Alan E. Kazdin, Ingram Olkin, and John Pintofor their helpful comments on earlier drafts.Correspondence should be addressed to Pamela M. Kato, The Children’s Health Council, 700Sand Hill Road, Palo Alto, CA 94304.

276 P. M. Kato and T. Mann

Several theories have been proposed to account for the psychological and physicalfunctioning of the bereaved. Some theories of bereavement propose that the be-reaved suffer because they have not resolved inner conflicts associated with the stagesof loss and have failed to reinvest in a new relationship. Other theories propose thatpeople suffer following bereavement because bereavement is a major life stressor, orbecause bereavement represents a loss of social support. Although these theoriescome from different schools of thought, they must account for two consistently dem-onstrated findings. First, the event of bereavement tends to be experienced differentlyby men and women. Men have been shown to experience more depression thanwomen (Stroebe & Stroebe, 1993; Umberson, Wortman, & Kessler, 1992), and moremen than women die following loss of their spouse (Jones & Goldblatt, 1987). Sec-ond, bereavement has also been shown to be influenced by the characteristics of thedeath of the loved one. For example, an unexpected, sudden death is often associatedwith more intense and prolonged grief reactions than an expected death (Osterweis,Solomon, & Green, 1984).

To address the mental and physical suffering of individuals who experience the lossof a loved one, several researchers have carried out experimental trials in order to testthe effectiveness of psychological interventions for the prevention and treatment ofadverse grief reactions. As the research on the effectiveness of psychological interven-tions for bereavement accumulates in the literature, it is becoming increasingly im-portant to clarify and summarize the effectiveness of these programs. It is also impor-tant to keep in mind the prevailing theories of grief that account for the adversemental and physical consequences of bereavement, since they should guide the inter-ventions (Price, Cowan, Lorion, & Ramos-McKay, 1989). Finally, it is equally impor-tant to address factors known to account for the different reactions of bereaved indi-viduals. Interventions that account for these factors tend to be more effectivetreatments for subgroups of the population that are often the hardest to reach and athighest risk for adverse outcomes (Kato & Mann, 1996).

In this paper, we critically review theories of bereavement and synthesize qualitativeand quantitative information on bereavement interventions. First, we briefly describefour main theories of bereavement, then we combine a qualitative review of the be-reavement intervention studies with a quantitative assessment of the studies to assessthe overall effectiveness of psychological interventions for the bereaved. We use meta-analysis as a statistical procedure to integrate and quantify the findings from these studies.

THEORIES OF BEREAVEMENT

Psychoanalytic Theories

The earliest theories of the grief reaction are in the psychoanalytic tradition (Freud,1917). Freud suggested that in the process of normal mourning, individuals withdrawlibido from the lost object (the deceased) and then reinvest libido in a new object (anew spouse or love interest). This behavior is driven by a drive to reduce the emo-tional and physiological arousal associated with the loss. Pathological grief resultswhen an individual has a predisposition to obsessional neurosis. Individuals with anobsessional neurosis are often ambivalent about the loss and blame themselves for it(Freud, 1917).

Psychoanalytic theories do not explain why bereaved men would suffer more physicaland psychological symptoms than bereaved women. They do, however, predict that peo-

Interventions for the Bereaved 277

ple would more quickly resolve an expected loss than a sudden loss. In an expected loss,people can begin the process of withdrawing and reinvesting libido earlier. They also ac-count for some physical symptoms such as those associated with anxiety and depression.

An intervention based on a psychoanalytic theory might focus on working throughthe bereaved’s ambivalent feelings toward the deceased, resolving self-blame for theloss, and encouraging the bereaved to reinvest their libido in a new love object. In ad-dition, bereaved people who are predisposed to obsessional neurosis might be tar-geted in these interventions since they are at highest risk for pathological grief accord-ing to this model.

Stage Theories

Stage theories of bereavement, such as those proposed by Bowlby (1980) and Kubler-Ross (1969), are influential among clinicians. Bowlby emphasized four stages ofmourning following loss, including shock, searching, depression, and reorganization/recovery. He noted that many species of animals, including human infants, experi-enced separation anxiety in response to disrupted attachments to their parents. Heextended his theory to adults and suggested that grief was a reaction to disruption ofan attachment bond between adults and their loved ones. Bowlby claimed that the re-sponse progressed through a systematic pattern of stages.

Kubler-Ross (1969) proposed that individuals go through phases of denial, anger,bargaining, depression, and acceptance. The phase of denial protects the bereavedfrom experiencing the extent of the reality all at once. Denial and shock are consid-ered to be normal responses as long as they are not prolonged. As the bereaved comesout of denial, he or she often begins to wrestle with coming to terms with the loss. Thebereaved often become angry as they recognize their lack of control over the loss. Ex-pression of anger is seen as a healthy response, in contrast to withholding emotions,during this stage. After experiencing anger, the bereaved often bargain for the returnof their loved one with promises of changes in beliefs or behavior. When bargainingefforts are acknowledged as futile, the bereaved acknowledge the hopelessness of thesituation and often experience a period of depression or despair. The bereaved oftenreport feeling acutely sad and empty in this stage. Finally, the bereaved fully acceptthe loss and can reminisce about the deceased without excessive emotional upheavals.Signs of resolution are apparent when the bereaved begin to reinvest in social activi-ties and show positive expectations for the future.

Pathological grief is one course that one may take through a stage model. If certainstages must be passed through to complete the grieving process, then individuals whofail to complete tasks at certain stages become impaired at later stages and may ulti-mately fail to resolve the loss (Engle, 1961). Critics of stage theories (e.g., Wortman &Silver, 1989) argue that stage models of grief have limited generalizability because: 1)distress is not a necessary feature of bereavement (e.g., Lund, Caserta & Dimond,1986), and 2) the specific duration of each stage and the time to resolution are notspecified so that instances of failures to resolve the loss with no signs of pathology canbe found years later (e.g., Wortman & Silver, 1987). Stage theorists have responded tothis criticism by arguing that the stage model is not a linear model so that people canskip stages, go back to earlier stages, etc. This clarification, however, renders stage the-ories difficult if not impossible to test empirically.

Stage theories fail to explain why males often experience worse mental health out-comes than females during bereavement, but they do predict that in an expected loss,

people would begin proceeding through the stages sooner (and hence recoversooner). Finally, these theories do not fully account for the adverse physical healthoutcomes associated with grieving.

Despite these theoretical drawbacks, an intervention based on a stage theory can becarried out. It might facilitate the bereaved through the stages of grief and loss. Much ofthis work would most likely involve “working through” or “processing” negative affectassociated with the losses leading to resolution in the final stages of the grief reaction.

Stress Theories

Stress theories account for bereavement outcomes by describing bereavement as a ma-jor life stressor (Holmes & Rahe, 1967). According to this approach, bereavement isparticularly stressful because it requires more adjustments to be made than other lifeevents. Stress theories suggest that the experience of bereavement may affect mentaland physical health through either direct or indirect routes.

There may be a direct effect of the stressful experience on the brain’s physiologicalresponse, such as a release of serotonin, which is associated with adverse mentalhealth outcomes such as depression and anxiety (Reynolds, 1994). Other direct ef-fects include the psychoneuroendocrine response of suppressed immune functioningand endocrinological changes. These responses are associated with increased suscep-tibility to infectious diseases (see Cohen & Williamson, 1991, for a review), cancer andcoronary heart disease (Martikainen & Valkonen, 1996). These direct physiologicalresponses to stress have been observed among the bereaved and may account for theiradverse health outcomes (e.g., Bartrop, Lazarus, Luckherst, & Kiloh, 1977; Stroebe &Stroebe, 1993). Bereavement interventions based on direct effects of stress may in-volve trying to change physiology using biofeedback and hypnosis following the loss.

Bereavement may also have indirect effects on health through cognitive (e.g., Laz-arus & Folkman, 1984) and behavioral (e.g., Stroebe & Stroebe, 1987) pathways. Ac-cording to cognitive appraisal theories, adverse outcomes associated with stressfulevents can be more precisely predicted depending on a person’s appraisal of thestressfulness of the event and the person’s perceived ability to cope with that event.Those who appraise the event as stressful will have more adverse outcomes than thosewho do not perceive the event as stressful.

Appraisal theories provide a plausible explanation for divergent outcomes duringbereavement. These cognitive theories would predict that men will experience moreadverse outcomes from bereavement than women because they are more likely to ap-praise the demands imposed by bereavement as exceeding their coping capacities. Inparticular, male gender role scripts may make it difficult for men to ask for help or ex-press their emotions (Eisler, Skidmore, & Ward, 1988; Pleck, 1995). Appraisal theo-ries would also predict that people have more adverse reactions to an unexpectedthan expected loss because people appraise unexpected losses as more stressful thanexpected losses.

Interventions based on indirect effects of cognitions may address people’s apprais-als of the event, and may try to help them find ways to see the event as within theircoping capacities (e.g., consciousness raising groups that focus on the advantages anddisadvantages of traditional gender role scripts). They could also target men andwomen with different approaches to address their differing appraisals of loss. Theymight also target a focused intervention for those at greatest risk of maladaptive griefreactions, those who have experienced an unexpected loss. This intervention might

guide the bereaved to appraise the unexpected loss in a way that promotes effectivecoping efforts.

In addition to cognitions, behavioral changes associated with bereavement may alsohave an indirect effect on health outcomes observed during the grieving process. Forexample, following the loss, the bereaved may adjust their lives in ways that radicallyand adversely change their patterns of eating, exercising, and sleeping, and these be-haviors may in turn impact the health outcomes observed among the bereaved in afeedback loop (Stroebe & Stroebe, 1987). In a study of a Finnish sample of bereavedmen and women, the bereaved showed excess mortality rates for accidental, violent,and alcohol-related deaths (Martikainen & Valkonen, 1996), outcomes clearly relatedto maladaptive behavior patterns.

According to this model of indirect effects of behaviors, gender differences can beexplained if men engage in more maladaptive behaviors than women following loss.There is support for this explanation. Men are more likely to engage in unhealthy be-haviors to cope with their loss (see Umberson, Wortman, & Kessler, 1992). In addi-tion, differences in outcomes by the type of loss can be explained if people who expe-rience an expected loss engage in more adaptive behaviors than those who experiencean unexpected loss. In any case, interventions that target behaviors as having an indi-rect effect on health may have a focus on teaching the survivor how to perform activi-ties that used to be done by the deceased (e.g., cooking, driving, or paying bills).

Social Support Theories

Social support theories conceptualize bereavement as a loss of an important part of aperson’s network of friends or family members. The loss of a spouse is often conceptu-alized as a loss of the emotional, instrumental, and financial aspects of social support.Thus, effects of bereavement on the quantity and quality of one’s social support net-work can have both direct and indirect effects on the bereaved’s physical and mentalhealth functioning.

Two models seem to explain the relationship between social support and healthoutcomes (Cohen & Wills, 1985). One model, the main effect model, proposes thatpeople gain health benefits directly through social support regardless of their stressstatus. Direct effects are often found in studies in which people’s level of integrationin a large social support network is measured (Cohen & Wills, 1985). This model ex-plains gender differences in response to bereavement. Research on gender and sup-port has noted that women have more extensive social support networks than men(Kessler, McLeod, & Wethington, 1985). This being the case, women are thought tofare better during bereavement because spousal loss does not constitute as large a lossin their overall social network as it would for men (Antonucci & Akiyama, 1987). Thedirect effect model may explain why one would react differently to an unexpected versusexpected loss if it can show that an unexpected loss disrupts social networks more thanan expected loss. A bereavement intervention based on the main effect model of socialsupport might involve integrating the bereaved into larger social support networks.

The other model of social support is the buffering model. According to this model,people’s social support systems buffer them from the adverse effects of stress, therebypreventing adverse health outcomes. Support for this model comes from studies inwhich people indicate that social support helps them cope with stressful events. Thismodel would predict that men suffer more than women when they lose their spousebecause they have fewer emotional resources than women to cope with the stress of

bereavement. Support for this prediction can be found in research on gender andsupport, which shows that women experience more supportive relationships thanmen (Flaherty & Richman, 1986; Leavy, 1983). This model would also predict that un-expected losses are more damaging because they impair the bereaved’s access to orability to use instrumental or emotional support to buffer the stress of the sudden loss.A bereavement intervention based on the model of the buffering effects of social sup-port might provide the bereaved with social support that provides coping resourcesand teaches coping skills.

Why Use a Psychological Intervention?

A psychological intervention is a natural choice as an intervention for bereavementbecause bereavement is an interpersonal life event. Interventions may help to reducethe intensity of the grief response and speed up the process of recovery, or they mayreduce the negative physical consequences of bereavement. As we described earlier,psychoanalytical interventions for bereavement may involve psychoanalysis, or work-ing through grief. An intervention based on the direct effects model of bereavementmight employ biofeedback or hypnosis. The indirect effects model of bereavementcalls for interventions that concentrate on adjusting cognitive appraisals, promotingpositive health behaviors, and consciousness raising. An intervention based on socialsupport theories would attend to the bereaved’s needs for a social support networkand the supportive aspects of these networks that promote effective coping.

In response to the mental and physical suffering of bereaved individuals, research-ers and clinicians have devised psychological interventions for the prevention andtreatment of pathological grief. We review empirical studies of bereavement interven-tions and conduct a meta-analysis of the results of these interventions in order to as-sess their overall effectiveness.

QUALITATIVE OVERVIEW

Bereavement interventions have taken the form of individual therapy, family therapy,and group therapy. In addition, within individual therapy and within group therapy,several different types of interventions have been implemented. For example, individ-ual crisis intervention therapy, individual trauma desensitization therapy, individualhypnosis therapy, and individual psychodynamic therapy have all been used with be-reaved people. First we will review the studies evaluating the effectiveness of individualtherapy, regardless of which technique is used, and then we will review one familytherapy study, followed by the group therapy studies.

Studies were gathered through searches of Medline, PsycINFO, and DissertationAbstracts International databases using the keywords “bereaved” and “bereavement.”Studies were also gathered from reference lists of general articles on bereavement.Criteria for inclusion in the review were the following: 1) random assignment of be-reaved people to treatment and control groups, 2) the control group is recruited inthe same way as the intervention group, but is assigned to a wait list, 3) an adult sam-ple (over 18 years of age), and 4) initiation of treatment intervention following loss,rather than before. A total of 13 studies that fit the inclusion criteria were found.

Several otherwise sound studies were excluded because of failure to meet criteria 1(e.g., Horowitz, Weiss, Kaltreider, Krupnick, Marmar, Wilner, & DeWitt, 1984; Levy,

Derby, & Martinkowski, 1993; Schut, Stroebe, & van den Bout, 1997) or criteria 2 (e.g.,Lieberman & Yalom, 1992). These studies have self-selected samples in which inter-vention participants have chosen to join an intervention and control group membershave chosen not to participate. These two groups are not compatible, as research showsthat widows who choose to join support groups are significantly more stressed, de-pressed, angry, and anxious than widows who choose not to join (Levy & Derby, 1992).

Validity

The external validity of a study is questionable if a large percentage of people who arerecruited for the study choose not to enter it. External validity is also threatened if, af-ter beginning a study, participants who remain in the study differ from participantswho drop out or are lost to follow-up. Table 1 provides summary information on theexternal validity of the studies reviewed.

Internal validity is threatened if participants who drop out of the control group dif-fer from participants who drop out of the intervention group. Only two studies as-sessed internal validity by comparing control group dropouts to intervention groupdropouts. They found no differences (Gerber, Wiener, Battin, & Arkin, 1975; Vachon,Lyall, Rogers, Freedman-Letofsky, & Freeman, 1980).

INDIVIDUAL THERAPY

Four studies of the effects of individual therapy on bereaved people met inclusion cri-teria. The interventions differ from each other in type, as well as in duration, and inwhether or not trained therapists were used. In addition, some interventions werecarefully controlled, while others were more flexible. Characteristics of the four indi-vidual therapy studies and the one family therapy study are described in Table 2.

One study evaluated the efficacy of a very flexible self-help program (Vachon et al.,1980). The program involved pairing widows with one of six other widows who had re-solved their own bereavement reactions and who had been specially trained to pro-vide supportive counseling to new widows, and showing them relevant community re-sources. There was little control over the duration or intensity of the interactions, andthe actual amount of interaction was unspecified. There was no mention made of theadequacy or appropriateness of the delivery of the intervention. In addition, exclu-sionary criteria were not strict, so certain widows who were not appropriate targets forthis type of intervention may have been included anyway (e.g., widows with severemental disorders).

Only four items from the 30-item General Health Questionnaire (GHQ) differenti-ated between widows in the intervention group and widows in the control group at 6months, and four different items differentiated between the two groups at 12 months.All of these items showed that the widows in the intervention group were adaptingbetter to the loss than widows in the control group. For the majority of items, how-ever, there was no difference between widows in the two conditions. At 24 months, sig-nificantly more widows from the intervention condition than from the control condi-tion moved from a rating of high-distress to a rating of low-distress on the GHQ. Thisstudy provides only moderate support for the hypothesis that the widow-to-widow pro-gram aids adjustment to grief. Few effects were found, and the only important effectwas found 24 months after the loss. In addition, at baseline before the start of the in-

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tervention, widows in the intervention group were significantly more likely to have “anumber of people to count on” than were widows in the control group. Since the re-searchers did not control for this baseline difference in their analyses, any conclusionsthat can be drawn about the efficacy of the support program are seriously limited.

One study looked at the effect of a bereavement intervention on participants whowere at high risk for morbidity (Raphael, 1977). Participants were judged as high riskif they 1) had a high level of perceived non-support in their social network, 2) had amoderate level of perceived non-support and the circumstances of the death were par-ticularly traumatic, 3) had a previously highly ambivalent relationship with the de-ceased, traumatic circumstances of the death, and any unmet needs, or 4) had a con-current life crisis.

High risk participants were randomly assigned to intervention or control condi-tions. The intervention was individual, non-directive psychotherapy, and was focusedon ego-support, expression of grief, and working through participants’ ambivalencein their relationship with the deceased. The treatment was applied “with varying levelsof psychodynamic sophistication,” and the number of intervention sessions per partic-ipant varied from one to nine sessions.

On the health questionnaire mailed 13 months after the loss, significantly more in-tervention participants than control participants were classified as having a “good out-come” (based on preassigned cut-offs on the questionnaire). When the measure isbroken down into components, it becomes clear that although there were differencesbetween the two groups on several measures (general aching, swollen joints, feelingsof panic, excessive tiredness, weight loss, smoking, alcohol use, and depression), themajor area of difference was in doctor visits. Participants in the control group had sig-nificantly more doctor visits than participants in the intervention group. However,this difference disappears if the intervention therapy visits are counted among thedoctor visits. This study gives some support to the classic finding that patients receiv-ing psychological counseling report fewer somatic complaints and make fewer doctorvisits than patients who do not receive therapy (Mumford, Schlesinger, & Glass, 1981).It is not clear if this intervention is helpful to widows beyond the level of somatic com-plaints. That is, it is unclear if these widows are actually feeling better physically, or ifthey are simply reporting fewer complaints on the questionnaire because they alreadyhave a place where their thoughts and feelings can be heard (i.e., in therapy).

Another study gives further support to the finding that patients in therapy reportfewer somatic complaints. The study looked exclusively at the effects of a bereavementintervention on medical outcomes (Gerber et al., 1975). The intervention consistedof brief therapy, in which the bereaved were aided in discussing their feelings andtheir relationship to the deceased, were given advice with financial and legal issues,and were helped in organizing social activities with friends and relatives. The interven-tion lasted 6 months, but over half of all interactions occurred over the phone.

The researchers measured how many of the bereaved people visited their doctors,how many were using medication, and how many felt ill but did not call their doctor.These evaluations were made at four time points: 1) baseline (loss–2 months), 2) dur-ing the intervention (2–5 months after the loss), 3) immediately after the intervention(5–8 months after the loss), and 4) long-term follow-up (8–15 months after loss). Theintervention group did not differ from the control group on these measures at base-line and during the intervention. However, at the third assessment, immediately afterthe intervention, significantly more of the participants in the control group had vis-ited their doctors, had used medication (both psychotropic medications and general

medications), and had felt ill (but had not called their doctors). In addition, analysesbased on gender reveal that for all these variables, the treatment was more effective withmale participants than female participants. All these differences (including the genderdifferences) disappeared, however, by the long-term follow-up (8–15 months after the loss).

One might assume that at the long-term follow-up the medical crisis was over, andthat participants in the intervention group simply recovered faster. The data, how-ever, reveal that this is not the case. At long-term follow-up, participants in both condi-tions made more doctor visits, used more medications, and felt ill (but did not calltheir doctors) more times than they had just after the intervention. This suggests thatthe positive effects observed among the intervention participants immediately afterthe intervention are simply indicative of a temporary improvement, not an earlier re-covery. One may suspect that participants in the intervention group retained theirpositive effects only for a short period following the intervention.

The final study of individual therapy compared the effects of three different be-reavement interventions with a control group of participants who received no inter-vention (Brom, Kleber, & Defares, 1989). The study only included participants whowere having symptoms of loss-related intrusions, denial, avoidance, anxiety, sleepless-ness, guilt, and for whom there was no indication that the problems were caused bypsychological disorders or disease. Participants were randomly assigned to a wait-listcontrol group, to trauma desensitization therapy (in which relaxation techniques are usedto help the participant confront the loss), to hypnosis therapy (in which hypnosis isused to help the participant confront the loss), or to psychodynamic therapy (in which thetherapist focuses on discovering and solving psychological conflicts related to the loss).

Compared to participants in the control group, participants in all three interven-tion conditions reported significantly fewer symptoms of a stress response syndrome(using the Impact of Events Scale) at the post-test. Although there are no other differ-ences between intervention and control participants on post-test measures, changescores show that participants in all three interventions improved more from pre-test topost-test than control participants on measures of anxiety and psychoneuroticism. Fi-nally, no significant differences were found on somatization, social inadequacy, agora-phobia, or anger, and inconsistent differences were found on hostility and traumasymptoms. In general, it appears that the interventions were most effective for symp-toms of post-traumatic stress disorder, and had minimal effect on the participants’other symptoms. Unlike the previous two studies, interventions in this study did notsignificantly reduce the number of somatic complaints the participants reported.

CONCLUSIONS

Three of the four studies of individual therapy found small and inconsistent improve-ments in the reported physical health of intervention participants (Gerber et al., 1975;Raphael, 1977; Vachon et al., 1980), while the other study did not find any improve-ments on physical health, but did find some improvements in stress reactions (Bromet al., 1989). Results from these studies must be considered with caution, however, be-cause of methodological flaws that make the studies difficult to interpret. In onestudy, intervention participants had more social support than control participants atbaseline, and not enough information was provided to allow analyses of covariance tobe conducted (Vachon et al., 1980). In addition, one of the studies failed to controlfor gender or the amount of time that passed since the loss (Brom et al., 1989), and

two of the studies failed to specify whether or not the loss was expected (Brom et al.,1989; Raphael, 1977). Finally, duration of the therapy varied from patient to patientin all studies, and from therapy to therapy in the one study that compared severaltherapies (Brom et al., 1989). All of these uncontrolled factors may impact the resultsof these studies and, in particular, may mask real effects of the interventions.

In all of the studies, health was measured with self-report questionnaires or numberof doctor visits, which makes the data difficult to interpret. It is unclear if participantswho receive therapy are actually healthier, or if they simply do not need to reporthealth problems because they have already vented them to a therapist. More researchon the effects of individual therapy on bereavement is needed before any solid con-clusions can be drawn, and interventions that are more clearly based on theories ofbereavement need to be implemented and assessed. Interventions assessed in thesestudies tended to use combinations of social support, stress, and psychodynamic mod-els, making it virtually impossible to test the different theories. In addition, studiesthat assess depression and coping as well as health outcomes are needed.

FAMILY THERAPY

One study examined the effects of crisis intervention therapy on the bereavement offamilies that had experienced a sudden death (Williams & Polak, 1979). The interven-tion was not described in any detail, but focuses on family system and environmentalstress factors, which are ignored in most other studies. The theoretical models describedabove were rejected as inadequate because the researchers considered them too person-centered. The researchers accompanied the local medical examiner to the homes ofthe bereaved, so the intervention often began as early as 1 hour after the death. Therewas no formal psychotherapeutic format to the intervention, and its duration and fre-quency were highly variable (from 2 to 6 sessions over 1 to 10 weeks). In addition, thecontrol families were not prevented from seeking psychiatric help outside the study.Some of the control families did so but the proportion of those that did was not reported.

Researchers measured physical illness, psychiatric illness, family functioning, crisiscoping, and intellectual functioning. Results are reported for 16 factors that emergedfrom a factor analysis. Although families were randomly assigned to conditions andmatched for age, socioeconomic status, education, and residential location, familiesin the treatment condition were more likely to have lost their relative to suicide or anaccident, had more family crises in the previous year, and had more destructive familyenvironments. These variables were used as covariates in all analyses. Six months afterthe death, the treatment families had a significantly less authoritarian pattern of fam-ily decision making, but reported more concerns about work, family, and socioeco-nomic well-being, and higher monthly expenses. There were no differences on the re-maining 13 factors. Eighteen months after the death, only the difference in authoritarianfamily decision making remained significant. Although it appears that family therapywas not effective in helping these families adjust to loss, no firm conclusions aboutfamily therapy in general can be drawn from only one study.

GROUP THERAPY

Eight studies that fulfilled the inclusion criteria examined the effects of group therapyon adjustment to loss. Most of the interventions consisted of support groups involving

lectures about the grieving process and open discussion, but a few interventions fo-cused on consciousness raising or cognitive restructuring. In addition, several of thestudies compared intervention participants to participants who had engaged in orga-nized social activities (in addition to non-intervention controls) to examine whetherthe effects of group therapy are general or specific. The characteristics of the 8 grouptherapy studies are described in Table 3.

Six of the eight studies found virtually no beneficial effects of the interventions.One study that did report consistently beneficial effects examined a treatment pro-gram that involved eight weekly 2-hour meetings (Polinskey, 1990). The interventionwas a support group of mostly female widows, and it consisted of lectures on the griev-ing process and social adjustment, as well as group counseling, freedom to vent feel-ings, instruction in relaxation techniques, and other activities such as journal writing,writing a letter to the deceased, and creating a memorial for the deceased. Most of theparticipants had been widowed for less than 6 months, although there were a few par-ticipants in each condition who had been widowed for up to a year. All participantshad signed up for a group therapy program and then were randomly assigned to ei-ther the intervention or a wait-list control group.

All participants were pre-tested and post-tested using the Grief Experience Inventory(Sanders, Mauger, & Strong, 1985), which has subscales measuring despair, anger/hos-tility, guilt, social isolation, loss of control, rumination, numbness, shock, somatization,and death anxiety. On each of these subscales, intervention participants significantlyimproved over the course of the study, while control participants showed no change.

In most studies, all participants improve with time, so the fact that these controlparticipants did not improve is unusual, and may be an important reason why this isthe only study in which intervention participants appear better-adjusted than controlparticipants at the post-test. It is possible that control participants did not show theusual improvement with time because they had wanted to be in a support group butwere required to wait. This alone could explain why the intervention participants aredoing so much better than the control participants at the time of the post-test. How-ever, this intervention does seem to be more intense than the other interventionsstudied, and the participants in the support group became very close to each other,formed friendships, and planned to stay in touch after the group ended.

The study was well-controlled, and the intervention and control participants wereidentical in terms of age, sex, relationship to the deceased, whether the death was ex-pected or unexpected, and length of time from the death to the start of the program.The only concern involving the post-test data is that the task of the last group sessionwas to discuss how the group had benefited each person in it. The self-report post-testwas conducted immediately after this discussion, which could have introduced criticaldemand characteristics. Otherwise, the study was a model of good experimental de-sign and control.

Three studies that involved similar interventions to the above (Polinskey, 1990)failed to show any beneficial effects. One of these studies examined a treatment pro-gram designed by the American Red Cross (Sabatini, 1988/89). The program had 14weekly meetings. Early meetings were pedagogic in nature, and focused on the dy-namics of grief and recovery. Later sessions were loosely structured support groups, inwhich members were encouraged to vent feelings and identify with others. Sessionsalso focused on teaching concrete skills, including managing somatic ailments andstress, and coping with loneliness and depression. As in the previous study, all partici-pants had revealed an interest in being in a support group, and half of the partici-

ks“M

pants were put on a waiting list. All participants were pretested and post-tested withthe Texas Revised Inventory of Grief (TRIG) (Fashingbauer, 1981), which measuresthe intensity of grief reactions.

Unlike the previous study, all participants improved from pretest to post-test, buttreatment participants did not improve more than control participants. Since thesecontrol participants showed improvements over time despite being put on a wait-listinstead of in a support group, it is not clear how to interpret the findings from Polins-key (1990). It does not seem appropriate to conclude that being placed on a waitinglist prevents participants from showing typical improvements over time, and thus thepositive findings from the Polinskey study should not be written off as merely an effectof preventing the control group from improving normally.

Researchers in the Sabatini (1988/89) study did find, however, that participantswho had expected the loss recovered more quickly than participants who had not ex-pected the loss. It is possible that an effect of the intervention program would havebeen detected if researchers had controlled for this important confound.

In another study with a similar intervention, researchers found inconclusive results(Weidaw, 1987; Zonnebelt-Smeenge, 1988; note: both studies analyzed the same inter-vention). Participants were mostly female widows (less than one third of the partici-pants were male) who had been widowed for only 2 months. Widows were contactedfrom the obituaries. The response rate was low (about 41% of contacted widowsagreed to participate) but this might be expected since the widows contacted were notseeking help. The intervention was similar to those described above, but only lastedfor four weekly sessions. In addition, it was not clear if all participants in the interven-tion condition attended all four meetings of the support group, and if control partici-pants received any support apart from the study.

Participants were assessed at pre-test and post-test with three subscales from Kincan-non’s short form of the MMPI. The scales used were those measuring hypochondria-sis, depression, and hysteria. No changes were found on the depression subscale. Onthe hypochondriasis and hysteria subscales, the intervention participants were signifi-cantly healthier than control participants at the post-test, even though neither groupshowed significant change from pre-test to post-test. This strange effect is due to theintervention participants showing a slight trend toward getting more healthy overtime and control participants showning a slight trend toward getting less healthy overtime. These effects are very small.

A third similar intervention was used with only male participants and found no ef-fects (Tudiver, Hilditch, Permaul, & McKendree, 1992). Sessions focused on informa-tion giving, sharing of feelings and mutual support, and also included lessons on lifemanagement skills, such as exercise, cooking, and financial and legal support. The in-tervention lasted 2 months, and follow-up data were collected at 2 months and 8 monthsafter the intervention. No significant differences between treatment and control par-ticipants were found at the 2- or 8-month follow-ups for any of the measures used inthe study (Goldberg General Health Questionnaire, Beck Depression Inventory (BDI),State-Trait Inventory, Social Adjustment Scale, or the Social Support Questionnaire).

Significant improvement over time was found for all participants, regardless of con-dition. This study gives no support for the effectiveness of support groups for widow-ers. It is not clear from this study whether support groups are not effective for men,whether they are not effective for bereavement at all, or whether this particular typeof support group is ineffective. Unfortunately, few other studies include sufficientnumbers of male participants to assess these hypotheses.

Four studies compared several types of interventions to wait-list control groups.One of these studies compared three different types of widows’ groups and found nodifferences between the three interventions, and only two small differences betweenthe intervention participants and control participants (Barrett, 1978). Participants at-tended either a support group (similar to those described above), a confidant group(in which they were paired with another widow for group meetings), a consciousness-raising group (in which they were made aware of how their experiences as widows re-late to their experiences as women), or a wait-list control group.

Researchers measured twelve different variables (such as health complaints, a 5-yearhealth prediction, intensity of grief, attitudes toward widowhood and remarriage, self-esteem, and life satisfaction). Intervention participants (as a group) improved morethan control participants on 2 of the 12 measures: a prediction of their health in 5years, and other-oriented attitudes. All participants, however, showed an increase inintensity of grief from pretest to post-test. Conclusions drawn from this study may bequestionable, as one third of the participants dropped out of the study after findingout the condition into which they had been randomized.

A study by Walls and Meyers (1985) found virtually no effects of three differenttypes of bereavement interventions. The researchers compared participants who wererandomly assigned to a cognitive restructuring group (which taught participants toidentify irrational thoughts and to use coping self-talk), a support group (similar tothose previously described), a behavior skills group (designed to get participants in-volved in pleasant social activities), or a wait-list control group. Groups had 10 weeklymeetings, followed by the post-test. Participants had not sought out treatment, but in-stead were recruited in funeral homes. The researchers did not specify what propor-tion of contacted participants actually participated in the study.

At baseline and after the tenth meeting, researchers measured depression (with theBDI and the Social Anxiety and Distress Scale [SADS]), irrational beliefs, pleasantevents, and life satisfaction. They found no significant beneficial effects of treatmenton any of the measures. Participants in the cognitive restructuring group and the be-havior skills group reported fewer and less enjoyable pleasant activities than partici-pants in the support group and the wait-list control group. Follow-up data from a sub-set of the participants 1 year later revealed no changes on the three measures thatwere testedµthe two depression measures and the measure of life satisfaction. Thestudy gives no support to the hypothesis that psychological interventions improve peo-ple’s adjustment to loss, and, if anything, finds some support for the oppositeµthat is,that psychological interventions can be harmful to widows.

The remaining two studies both compared a support group (similar to those de-scribed above) to a social activities condition, as well as to a wait-list control group(Constantino, 1988; Duran, 1987). In both studies, participants in the social activitiescondition met weekly for 6 weeks and participated in planned social activities, such asvisiting museums, seeing plays, playing games, bowling, or going out for dinner.These interventions were designed to help assess whether benefits from supportgroups are specific to the support that is given, or whether the benefits are general,and are due to having a group of people to see, or to having something to do.

One of the studies included only females and did not control for the time since theloss (Constantino, 1988). In fact, the majority of participants in the sample had beenwidowed for over 1 year already, and many had been widowed for 5 or more years.The other study included males and females who had been widowed for less than 6months (Duran, 1987).

Positive effects were shown for the social support condition in Constantino (1988).At the post-test, participants in the support condition were significantly less depressed(using the BDI and the Depression Adjective Checklist) and significantly better ad-justed (using the Revised Social Adjustment Scale) than participants in the controlcondition. Both studies, however, reported several negative effects of the social activi-ties condition. In Constantino (1988), participants in the social activities group wereworse off on all three measures than both support group participants and control par-ticipants. In Duran (1987), no effects were found on the Texas Inventory of Grief, andat post-test, control participants reported less depression (on the Zung DepressionScale) than participants in the social activities condition. In addition, participants inthe social activities condition reported less perceived social support than participantsin the other two groups. Therefore, in both of these studies, social activities interven-tions had harmful effects.

Finally, since the Duran (1987) study reported data separately for male and femaleparticipants, it is possible to assess the effects by gender. In general, the support grouphelped male participants but harmed female participants, whereas the social activitiescondition harmed male participants but had no effect on female participants. The dif-ferent outcomes experienced by men and women in this study illustrate the impor-tance of analyzing results separately by gender. If studies include male and female par-ticipants but are not analyzed by gender, effects of interventions may be masked byopposing gender effects, as could have been the case with this study.

CONCLUSIONS

Only two of the eight studies of group therapy found consistent beneficial effects ofthe interventions on bereaved participants (Constantino, 1988; Polinskey, 1990). Forthe most part, the Polinskey (1990) study was conducted appropriately and controlledthoroughly. It did not have any notable distinctions from the other studies in terms ofthe intervention type, duration, or quality. Participants did, however, give self-reportpost-test measures immediately after a group discussion of how the program had ben-efited each member, which may have artificially inflated their post-test assessments. Inaddition, unlike other studies, control participants did not show improvements overtime. The Constantino (1988) study, however, can hardly be described as a bereave-ment study, since only a small fraction of the participants had been bereaved even inthe past year. It may be more properly thought of as a study of widows long after beingwidowed, and hence it is unclear if its results can be generalized to widows who are re-cently bereaved. The other six studies failed to provide support for any type of grouptherapy, and showed that one type of support group (social activities groups) actuallywas harmful to participants (Constantino, 1988; Duran, 1987). The studies, however, areriddled with methodological problems that could be masking effects of the interventions.

Several of the six studies did not control for the length of time since the loss, and inone of the studies the majority of participants had been widowed for several years be-fore the intervention started (Barrett, 1978). One of the studies found that widows re-covered faster if the death had been expected rather than unexpected (Sabatini,1988/89), and most of the other studies failed to control for this factor. Similarly,while one study included participants of both genders and controlled for gender ef-fects (Duran, 1987), the other studies that included participants of both genders didnot control for it, possibly masking effects of the interventions.

In one of the studies (i.e., two studies of identical intervention and identical dataset), it was not clear to what extent intervention participants attended the interven-tion (Weidaw/Zonnebelt-Smeenge, 1987/1988), nor was it consistently clear that con-trol participants in these studies had not attended any sort of support group. Severalstudies had large numbers of drop-outs (Barrett, 1978; Weidaw/Zonnebelt-Smeenge,1987/1988), and others failed to specify drop-outs but used procedures that tend toresult in large numbers of drop-outs (Walls & Meyers, 1985). Finally, all the issues in-volved with self-report assessments of health and doctor visits that were mentioned inthe discussion of individual therapy are problems here as well.

Studies that carefully control for possible confounding factors (gender, expected-ness of death, time since loss), that control and document that intervention partici-pants receive the intervention and control participants receive no intervention, andthat have drop-out rates lower than 25% are needed. In addition, researchers need toreport their data in such a way that effects of gender can be assessed, as it is very likelythat different interventions will be effective for males and females.

QUANTITATIVE REVIEW AND META-ANALYSIS

Inclusion Criteria

Criteria for inclusion were the same as for the qualitative review, with the additionalconstraint that there be enough information available in the article to compute effectsizes of group differences. When studies did not report enough information to allowthe computation of effect sizes, we tried to contact the authors of the studies to get theadditional information. We were able to attain additional information for only onestudy, and that information allowed us to compute effect sizes for some of the vari-ables mentioned in the paper (Tudiver et al., 1992).

Based on these criteria, 11 studies were included in the meta-analysis (Barrett, 1978;Brom et al., 1989; Constantino, 1988; Duran, 1987; Gerber et al., 1975; Polinskey, 1990; Sa-batini, 1988/89; Tudiver et al., 1992; Walls & Meyers, 1985; Weidaw/Zonnebelt-Smeenge,1987/88; Williams & Polak, 1979). Two studies were excluded solely because there wasnot sufficient information in the article to compute effect sizes of group differences,thus constituting a failure to meet the last criteria (Raphael, 1977; Vachon et al., 1980).

Effect Sizes

Standard effect sizes were computed to support inferences about direction, magni-tude, and consistency of effects. A standard effect size estimate, Cohen’s (1977) d, isthe mean difference on dependent variables between the treatment and controlgroups divided by the standard deviation of the control group:

When differences between treatment and control groups were not significant andstatistics were not reported (in papers that did report the relevant statistics for signifi-cant effects), an effect size of .00 was inferred (see Barrett, 1978; Duran, 1987; Gerberet al., 1975). Effect sizes were computed for measures of depression and grief, physical

dXt Xc–

Sc------------------=

symptoms, and other psychological symptoms (e.g., anxiety, neuroticism, stress). Apositive effect size implies that the treatment group had a better outcome than thecontrol group, and a negative effect size implies that the treatment group had a worseoutcome than the control group. According to rough guidelines set forth by Cohen(1997), an effect size of .20 is considered small, .50 is considered medium, and .80 isconsidered large.

After computation of the individual study effect sizes, these values were averaged toobtain an estimate of the average population effect size for treatment vs. control par-ticipants, for the three main categories of depression, physical symptoms, and othersymptoms, as well as one global measure across all types of variables. When studies re-ported more than one measure for the same type of outcome (e.g., two different mea-sures of depression), the measures were averaged into one measure to use when calcu-lating the average effect size. In addition, only measures taken directly after theintervention ended (and corresponding control group measures) were used for eachstudy, even though a few studies reported additional follow-up measures.

The average effect size for bereavement interventions on measures of depressionand grief was .052. This estimate was based on sixteen effect sizes. The average effectsize for interventions on measures of physical symptoms was .272, and this estimatewas based on eight effect size measures. The average effect size for other psychologicalsymptoms was .095 and was based on 13 effect size measures. Using all 37 effect sizemeasures, the global average effect size across all types of variables was .114.

The global effect, and the effects for depression and other psychological symptoms,are not even large enough to qualify for the designation of “small.” Effects for physicalsymptoms can be considered small.

To address the four psychological theories of bereavement, all effect sizes fromeach type of intervention were averaged to create a global measure of the efficacy ofeach type of intervention. As before, if a study included more than one measure of aparticular construct, those measures were averaged into one measure that was then in-cluded in the overall effect size for that type of intervention. Stage theories of bereave-ment were not addressed in the interventions, and only one study included a psycho-dynamic intervention, so effect sizes can only be evaluated for social support interventionsand stress interventions.

Eight studies tested social support interventions. The average effect size across 16measures is .295. Two studies included a social activities intervention, and the averageeffect size from four measures in those studies is 2.348. Finally, across the four studiesthat tested stress interventions (cognitive restructuring, crisis intervention, trauma de-sensitization, behavioral skills, and hypnosis), the average effect size across 13 measuresis 2.006. The social support interventions had a small helpful effect, but the social ac-tivities interventions led to a small harmful effect. The stress interventions had no effect.

DISCUSSION

The effect sizes for these studies suggest that psychological interventions for bereave-ment are not effective interventions for the depression experienced by the bereaved.Only 2 of the 10 studies that measured depression showed large effects of the inter-vention, and one of those studies (Constantino, 1988) was not well controlled. The in-terventions are not effective for the other psychological symptoms experienced by thebereaved either, with studies showing almost as many negative effects as positive ones.

There is some evidence that these interventions are effective for the physical symp-toms often experienced by bereaved individuals, although these effects were small.The largest effects of interventions on physical symptoms came from self-report mea-sures of somatization and hypochondriasis, and no effects were found on the moreobjective measures of illnesses, doctor visits, and medication use.

There are three types of conclusions that may be drawn from these results. First, it ispossible that interventions for the bereaved are, in fact, not effective in relieving thesymptoms of bereavement. Perhaps the experience of bereavement is simply too in-tense, or too stressful, to be impacted by a psychological intervention, and relief onlycomes with time. Second, and more likely (given the extensive literature on psycho-logical interventions for depression), perhaps psychological interventions for the be-reaved can be effective, but the interventions evaluated in these studies were not pow-erful enough to relieve symptoms as intense as those felt by bereaved people. Inparticular, while the interventions evaluated here sometimes lasted for 8 or moreweeks, none of the interventions met more than one time per week, and sessions wererarely longer than 1 hour. In addition, most of the interventions evaluated here werenot based on any particular theory of bereavement, and effective interventions willmost likely be based on theory (Price, Cowan, Lorion, & Ramos-McKay, 1989).

A third conclusion that may be drawn from these results is that it is possible for psy-chological interventions to reduce the suffering associated with bereavement, but thatmethodological problems with these studies have prevented effects from being de-tected. Small treatment effects may not have been detected in some of the studies be-cause of their small sample sizes. In addition, many of the studies here fail to ensurethat participants in intervention conditions actually receive the intervention, and thatparticipants in the control conditions do not receive some other intervention. Thisproblem can also prevent effects of interventions from being detected. Low recruit-ment rates and high dropout rates may skew the data to such an extent that real ef-fects are masked, and they will also undermine the validity of any conclusions that aredrawn, especially in light of research showing that there are significant differences be-tween people who join and who do not join bereavement studies (Levy & Derby, 1992;Stroebe & Stroebe, 1989/90). In addition, several of the studies reported here usedunreliable measures of physical and mental health, which can also prevent the detec-tion of real effects.

Another important problem with the studies reported here is that they do not ana-lyze data separately by gender. Not only have men been shown to be more adverselyaffected by the loss of a loved one than women, but it seems likely that different inter-ventions will be effective for men than for women. Indeed, in the two studies reportedhere that both included male subjects and appropriately assessed gender effects, menand women were differentially impacted by the intervention (Duran, 1987; Gerber etal., 1975). Thus, in studies that do not assess gender effects, or that do not control forgender in their experimental samples, real effects of the intervention may be maskedor diluted by opposing gender effects. Similarly, the studies reported here do not rou-tinely control for whether the loss was expected or unexpected, which may also maskeffects of the intervention.

Future studies of bereavement interventions need to avoid these methodologicalproblems. They should include more participants so that they have more power to de-tect small effects, should analyze data separately by gender and by expectedness ofloss, and should either make preventing dropouts a priority or should conduct analy-ses that account for pre-existing differences between the intervention and control

groups, and between dropouts and participants who remain in studies. Studies needto use more objective measures of physical health, and they need to ensure the integ-rity of the experimental conditions. If future bereavement studies take these factorsinto account, we will be able to draw more definitive conclusions from them.

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A synthesis of psychological interventions for the bereaved

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