“Do not put your faith in what statistics say until you have carefully considered what they do not say.” ~William W. Watt
I’m going to really go out on a limb here. Forthcoming: one of those big assumptions about humankind in general. Consider yourself warned.
Here it is: I don’t believe (you still with me?) that people like to see others suffer.
Oh, I can hear the uproar now. The Milgram experiment! The Nazis! The African slave traders! The Spanish conquistadors!
Ok–get it all out of your system. So maybe that statement’s debatable. But how about coming back with me to this smaller point: I don’t believe that people like to see those close to them suffer. Have we come to some sort of the meeting of the minds, even begrudgingly?
And a corollary of this, is that when someone we care about is suffering from the grief of having lost a loved one, we want to do what we can to ease their suffering, partly by getting them the best post-bereavement interventions available. [Do I mostly have people with me now?]
Fortunately, all grieving now is in an era where numerous interventions are available to help the bereaved work through sadness and loss, so we have much to offer or suggest to the mourning friend.
And although the following seemed pretty obvious to me–obvious enough that you didn’t really have to say it, if you know what I mean-if the researchers feel better proclaiming why we’ve developed and use all these interventions–well, who am I to stop them?
So here comes Field et al, in 2004, and shares the following illuminating information:
“Most bereavement services are based on the assumption that loss through death challenges coping abilities and that supportive interventions may facilitate post-death adaptation, reduce complicated grief reactions and promote wellbeing.”
You’ll never guess–I thought these services were about facilitating adaptation and promoting wellbeing, too! You know what they say about great minds.
And precisely what are these services alluded to by Field and his fellow authors? Well, they’re happy to tell you, listing them in a somewhat curious way, perhaps to keep your attention:
- Bereavement Support
- Bereavement Counseling
- Grief Therapy
- Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT), Cognitive Grief Therapy (CGT)
- Family Therapy, Group Therapy
Looks pretty darned good, right?
Well, it does, in fact, look like there are a lot of options for ‘promoting well-being’–or it did look that way–until a ‘meta-analysis’ sneaks up on you and pulls the carpet out from under your sense of having a veritable smorgasbord of treatments.
Never trust a sneaky meta-analysis, I say. For it won’t let simple, comforting research alone. Oh, no, it will look into it further, all the while carrying on about randomized-controlled trials, and in the end, options that seemed to hold out hope in assisting recovery from grief, you will soon find, might just as well be sitting there whistling Dixie, for all the help–claims the meta–they really give you.
Sometimes the research bereavement world can be a dark one.
Let’s take a look at a particularly ambitious meta-analysis, one that analyzed 74 studies that addressed a number of treatments for conditions and emotions associated with bereavement. In “Bereavement care interventions: A systemic review,” Amanda L. Forte and her cohorts surveyed studies that addressed a wide range of treatments, varying from psychoanalysis to psychopharmacology to a variety of group, individual and marital therapies.
It seemed like the answers to one of life’s great questions had to lie in the hands of Ms. Forte and company. What, truly, can assist the bereaved in coming to terms with loss? It’s an answer it behooves us all to know.
And, what do we find out from their study, as we should have realized, perhaps, living in an era of diminished expectations, as we do?
Ok–and. . .?Well, meds are effective if the bereavement has morphed into clinical depression.
That’s it. And nothing. Beyond that fairly obvious assessment–there’s nothing else the study can offer to those who so badly want to help their friends and loved ones process their grief and sorrow through the best means available.
The researchers don’t like the studies they’ve seen. The studies are missing the–everybody now!–randomized controlled trial (RCT) setup that is what researchers dream about at nights, and ruminate on during the days.
There is thus no rigorous (translation: RCT), evidence-based recommendation Forte et al can offer regarding the treatment of the bereaved, based on their meta-work.
Like that? Like ‘we don’t know, got nothing good to tell you’ as a response to your query about how best to help your grieving friend?They write, “for all attempts to diminish grief per se, no consistent pattern of treatment benefit has been established across well-designed experimental studies.”
But surely Forte et al stand alone on this pedestal of pessimism? What do other, perhaps more optimistic, researchers recommend?
What of Margaret Stroebe, who compiled the veritable Handbook of Bereavement:Theory, Research, and Intervention? Surely Dr. Stroebe knows what we can recommend to help those suffering. With Henk Schut, she puts together an article that holds out promise and hope in its very title: “Interventions to enhance adaptation to bereavement.” Aaah–here, at long last–a plan to help the mourner.
Stroebe and Shut, too, go through the available research (a veritable meta-analysis, I say) and conclude–yet again–that research does not indicate success for any studied intervention. They write,
“A comprehensive, updated review of empirical studies in these categories leads to the following conclusions: Routine intervention for bereavement has not received support from quantitative evaluations of its effectiveness and is therefore not empirically based. Outreach strategies are not advised, and even provision of intervention for those who believe that they need it and who request it should be carefully evaluated” [italics mine].
I like this study in that it not only fails to support any intervention, but adds the nice touch where it encourages the practitioner to carefully evaluate any request for help from a mourner. I mean–we uninformed think we should get our friends help just because they’re asking for help? Preposterous.
And just when you think you might have found a meta-analysis that makes it safe to think there might be something to offer the bereaved. . .there’s an undercurrent to the study that pulls you back to helplessness. In “The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review,” the meta-analysis summarizes results from 61 controlled studies to “examine. . .the absolute effectiveness of bereavement interventions immediately following intervention and at follow-up assessments.”
And–lo and behold-the authors actually do, finally, find some effectiveness in therapeutic interventions. You have to look closely to find the statistical significance, but–tepidly, it’s true, but nonetheless–the authors write, “Overall, analyses showed that interventions had a small effect at posttreatment.” Aha!
All is not lost, you think.
But, sadly, the researchers won’t leave you with even that cold comfort. For what did they find? These mildly helpful interventions “had no statistically significant benefit at follow-up.” Let a few weeks pass–and the treatment’s as useful to your friend as if she’d stayed home and pulled out her knitting.
If you think that’s disheartening–and, to be honest, I do–you clearly haven’t taken a look at Robert Neimeyer’s 2000 study. If you still held out hope that you could get help for a mourning friend, “Searching for the meaning of meaning: Grief therapy and the process of reconstruction,” ought to take care of you.
For here comes another sneaky meta-study analyzing 23 studies on grief therapy published between 1975 and 1998. For inclusion in Neimeyer’s paper, the research had to 1) offer a ‘psychosocial intervention,’ meaning psychotherapy, counseling, or a facilitated support group, and 2) to randomly assign participants who had experienced the death of a loved one to control and intervention groups. (There it is–the holy randomized controlled trial. Only RCTs will be meta-analyzed in this research–surely something great will come of this.)
Now here’s where it starts to get truly quirky. He utilized two measures to characterize the effectiveness of the studies. The first one, I offer to you to theorize–what would the researcher ask about these studies?
Okay, we’re back, with you on your honor that you thought this through. First assessment? An estimate of the degree of benefit correlated with the intervention. So far we’re all on the same page, I imagine.
But he doesn’t quit there. Oh, no. The second focus for his study is, believe it or not, an estimate of ‘treatment-induced deterioration, which represents the proportion of participants who are worse after treatment then they would have been if they had been assigned to the control group.’
For real–I couldn’t make this stuff up.
So he meta-analayzes, and what should he come up with?
You don’t find this stuff everyday. A study that claims that therapy post-bereavement actually makes people’s healing worse than leaving them to their own devices? Sometimes research can be a real downer.In a truly shocking statement, Neimeyer concludes that for participants who are not experiencing complicated bereavement, there was “essentially no measurable positive effect on any [outcome] variable” for the treatments, and “nearly one in two clients suffered as a result of treatment” [italics mine].
As the abstract succinctly concludes, the paper is “a comprehensive quantitative review of published randomized controlled (that’s the holy grail of the RCT) outcome studies of grief counseling and therapy [that] suggests that such interventions are typically ineffective, and perhaps even deleterious” [italics mine].
And for the moment, I’m with Prince Hamlet of “the rest is silence” fame when it comes to following this path any further. I’ll have to re-incarnate a different day, with a more positive outlook, and with meta-analyses with less attitude.
So with that I leave you, but I remind you that you need not be held captive by percentages–and you owe no loyalty to any meta-analysis you should meet in your life. The interventions for the bereaved are there to help–and many have found them helpful, whether they could prove that in a randomized controlled trial setting or not.
Remember: ”Do not put your faith in what statistics say until you have carefully considered what they do not say.” Which is a whole lot, when it comes to the value of interventions for mourners.
Currier JM, Neimeyer RA, Berman JS. The effectiveness of psychotherapeutic interventions for bereaved persons: a comprehensive quantitative review. Psychological Bulletin 2008; 134(5):648-61. [See manuscript here.]
Field D, et al. Survey of UK hospice and specialist palliative care adult bereavement services. International Journal of Palliative Nursing 2004; 10(12):569-76. [See abstract]
Forte A, et al. Bereavement care interventions: a systematic review. BMC Palliative Care 2004; 3(1):3.
Neimeyer RA. Searching for the meaning of meaning: Grief therapy and the process of reconstruction. Death Studies 2000; 24:541-558. [See full text here.]
Schut H, Stroebe MS. Interventions to enhance adaptation to bereavement. Journal of Palliative Medicine 2005; 8(Supplement 1):S140-S147. [See abstract]