The Effectiveness Of Interventions

Reviews of the effectiveness of bereavement intervention do not indicate a strong evidence base for much current clinical practice. The methodological flaws described at the start of the chapter have resulted in few studies that meet the criteria set by reviewers. Schneiderman et al. (1994) found only four articles out of 53 published that satisfied their criteria. These four studies had conflicting results and the authors concluded there was little sound evidence for or against bereavement programmes. Both a qualitative and quantitative approach was used by Kato & Mann (1999) in an analysis of 13 adult studies that met their criteria, including random allocation to intervention and control groups. They concluded that there was little strong evidence that intervention was effective. Small effect sizes only were found and theory and practice were not clearly linked in the research. The relevance of bereavement research to clinical practice is questioned by Allumbaugh & Hoyt (1999) who argue that the findings of their own meta-analysis reveal more about the limited nature of the research studies than answering any questions about the effectiveness of grief interventions. They found so few studies reporting long-term follow-up that they restricted their analysis to those studies reporting immediate post-treatment results. They concluded tentatively that recently bereaved clients who request help are more likely to benefit than those selected for research studies who have been bereaved longer. Also the studies surveyed in this meta-analysis did not support the common view that high-risk individuals benefit more from intervention than low-risk ones but the authors acknowledge definitions of 'high risk' varied so much across studies that this question remains open.

A later review of bereavement efficacy concurred with Allumbaugh and Hoyt's suggestion that self-selected clients are more likely to gain from bereavement intervention (Schut, Stroebe, Van den Bout & Terheggen, 2001). Schut et al. disagree with Allumbaugh and Hoyt's finding that early intervention is optimal. They divided preventive studies into primary interventions, secondary intervention for high-risk groups and tertiary intervention for complicated grief. They found little evidence of any lasting positive effects in primary prevention for adults and some indication of possible harm in some studies. The results for children seemed more promising. Secondary prevention studies gave mixed results with effects suggesting limited and temporary benefit. Tertiary intervention for people experiencing complicated grief gave more lasting and positive benefit but even with this type of intervention the gains were modest and studies were flawed.

Jordan & Neimeyer (2003) suggest explanations for the limited evidence base that is reported in these reviews and meta-analyses. Most bereaved people will recover over time with the support of their family and community. The nature of the intervention may not be appropriate for the bereaved minority who could benefit because of its timing, its length or its narrow theoretical model. Individuals selected for bereavement groups may be selected simply on the basis of bereavement status rather than screened for a number of variables as is usual with group therapy. This could affect the dynamics of the group and therefore its effectiveness. Outcome is assessed in simplistic ways by a reduction in pathological symptoms rather than by changed values or revised priorities, which may reveal that sadness is accompanied by increased personal growth. Gains for some individuals may be masked by losses for others so the overall effect is cancelled out rather than revealing subtleties between subsets of individuals. They conclude with recommendations for both researchers and clinicians, which reiterate the need for more rigorous methodology and closer integration between research and practice.

Dealing With Sorrow

Dealing With Sorrow

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