1. health and fitness
2. therapy

Clinical Psychology Review 31 (2011) 69–78
Contents lists available at ScienceDirect
Clinical Psychology Review
The prevention and treatment of complicated grief: A meta-analysis
Ciska Wittouck ⁎, Sara Van Autreve, Eva De Jaegere, Gwendolyn Portzky, Kees van Heeringen
Unit for Suicide Research, Department of Psychiatry and Medical Psychology, University Hospital, Ghent, Belgium
a r t i c l e
i n f o
Article history:
Received 10 February 2010
Received in revised form 12 September 2010
Accepted 14 September 2010
Keywords:
Meta-analysis
Complicated grief
Grief interventions
Prevention
Treatment
a b s t r a c t
Background: Bereaved individuals are at increased risk of mental and physical disorders, and prevention and
treatment of complicated grief is indicated. Earlier quantitative reviews have not focused on the effect of
bereavement interventions on (complicated) grief. Therefore the main objective of this meta-analysis was to
determine the short-term and long-term effect of both preventive and treatment interventions on
complicated grief.
Methods: Randomized controlled trials for prevention or treatment of complicated grief were identified
through a systematic literature search. Electronic databases and reference lists of earlier review articles served
as data sources. Data were analyzed with REVMAN 5.0.14.
Results: Fourteen randomized controlled trials met the inclusion criteria. Study quality differed among the
trials. Contrary to preventive interventions, treatment interventions yielded significant pooled standardized
mean differences in favor of the (specific) grief intervention at post-test and follow-up. During the follow-up
period, the positive effect of treatment interventions for complicated grief even increased.
Conclusions: Treatment interventions can effectively diminish complicated grief symptoms. Preventive
interventions, on the other hand, do not appear to be effective. Limitations of the meta-analysis and future
research options are discussed.
© 2010 Elsevier Ltd. All rights reserved.
Contents
1.
2.
Introduction . . . . . . . . . . . . . . . .
Method . . . . . . . . . . . . . . . . . .
2.1.
Inclusion criteria . . . . . . . . . .
2.2.
Search strategy . . . . . . . . . . .
2.3.
Data analysis . . . . . . . . . . . .
3.
Results . . . . . . . . . . . . . . . . . .
3.1.
Identification of studies . . . . . . .
3.2.
Study quality . . . . . . . . . . . .
3.3.
Meta-analyses . . . . . . . . . . . .
3.3.1.
Preventive interventions . .
3.3.2.
Treatment interventions. . .
3.3.3.
Prevention versus treatment.
4.
Discussion . . . . . . . . . . . . . . . . .
Acknowledgement . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . .
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⁎ Corresponding author. Unit for Suicide Research, Dept of Psychiatry and Medical
Psychology, University Hospital, De Pintelaan 185, 9000 Ghent, Belgium. Tel.: + 32 9
332 43 30; fax: + 32 9 332 49 89.
E-mail addresses: ciska.wittouck@UGent.be (C. Wittouck),
sara.vanautreve@Ugent.be (S. Van Autreve), eva.dejaegere@UGent.be (E. De Jaegere),
gwendolyn.portzky@UGent.be (G. Portzky), cornelis.vanheeringen@UGent.be
(K. van Heeringen).
URL: http://www.unitforsuicideresearch.be (C. Wittouck).
0272-7358/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2010.09.005
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69
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77
1. Introduction
Losing a loved one through death is a common life event. A mourning
process commonly follows such a loss, and most bereaved individuals go
through this process without severe mental or physical problems
(Middleton, Burnett, Raphael, & Martinek, 1996; Bonanno et al., 2002;
70
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
Bonanno, Wortman, & Nesse, 2004). Over time, mourners usually find a
way to cope with the loss and its consequences, therefore they are not in
need of grief interventions (Raphael, Minkov, & Dobson, 2001; Bonanno
et al., 2004; Zhang, El-Jawahri, & Prigerson, 2004; Stroebe, Schut, &
Stroebe, 2007). Nevertheless, a relationship between grief and the
development of poor mental and physical health is well documented
(Stroebe & Stroebe, 1993; Woof & Carter, 1997; Stroebe, Stroebe, &
Abakoumkin, 2005; de Groot, de Keijser, & Neeleman, 2006; Onrust &
Cuijpers, 2006; Miyabayashi & Yasuda, 2007; Stroebe et al., 2007). It is
estimated that about 9% of adults experiencing a loss develop
complicated grief reactions (Middleton et al., 1996; Raphael & Minkov,
1999).
Complicated grief (CG) is not (yet) an officially recognized (DSM)diagnosis, although the addition of CG as a diagnostic category to
DSM-V has received much support, (Horowitz, Bonanno, & Holen,
1993; Prigerson & Jacobs, 2001; Lichtenthal, Cruess, & Prigerson,
2004; Simon et al., 2007; Boelen & van den Bout, 2008; Dillen,
Fontaine, & Verhofstadt-Denève, 2008). In the late nineties two
research teams independently published a set of diagnostic criteria to
assess CG (Horowitz et al., 1997; Prigerson, Shear, et al., 1999).
Recently, these two diagnostic entities were integrated and the
concept of CG was renamed as Prolonged Grief Disorder (PGD). This
debilitating disorder is defined as a combination of separation distress
and cognitive, emotional and behavioral symptoms that can develop
after the death of a significant other. The symptoms must last for at
least 6 months and cause significant impairment in social, occupational and other important areas of functioning (Prigerson, Vanderwerker, & Maciejewski, 2008). The term CG instead of PGD will be
used throughout this paper to improve readability.
CG is associated with several mental and physical health problems,
e.g., depression, hypertension and cardiac problems, work and social
impairment, psychotropic drug use, and reduced quality of life
(Prigerson et al., 1997; Prigerson, Bridge, et al., 1999; Silverman et
al., 2000; Latham & Prigerson, 2004; Boelen & Prigerson, 2007;
Bonanno et al., 2007; Neria et al., 2007; Simon et al., 2007). In
addition, bereaved individuals are at increased risk of suicide and
suicidal behavior (Prigerson, Bridge, et al., 1999; Latham & Prigerson,
2004; Agerbo, 2005; Stroebe, Stroebe, & Abakoumkin, 2005; Stroebe
et al., 2007). CG thus clearly warrants prevention and treatment.
However, literature reviews and meta-analyses of studies of the
effects of bereavement interventions show only limited results. With
regard to preventive interventions, effects may indeed be limited or
absent (Neimeyer, 2000; Schut, Stroebe, van den Bout, & Terheggen,
2001; Currier, Neimeyer, & Berman, 2008). In addition, some studies
even show negative results, although treatment-induced-deteriorationeffects may be due to questionable statistical techniques (Neimeyer,
2000; Schut et al., 2001; Larson & Hoyt, 2007). Recent studies of
preventive interventions show more positive results, which may be due
to methodological differences, as participants are commonly selfreferred and the intervention is offered later in the bereavement
process. Interventions may indeed interfere with natural grieving
processes if they are implemented soon after the loss (Schut & Stroebe,
2005).
Interventions appear to be most effective when grief is more
complicated or when the risk of complications is higher, and when the
bereaved are self-referred (Allumbaugh & Hoyt, 1999; Jacobs &
Prigerson, 2000; Neimeyer, 2000; Schut et al., 2001; Jordan & Neimeyer,
2003; Schut & Stroebe, 2005; Currier et al., 2008).
To our knowledge, there have been three previous meta-analytic
investigations of bereavement interventions for adults (Allumbaugh &
Hoyt, 1999; Kato & Mann, 1999; Currier et al., 2008). The meta-analyses
of Allumbaugh and Hoyt (1999) and Kato and Mann (1999) were
published a decade ago. Since then, meta-analytic techniques have
highly evolved, and the methodological quality of trials regarding grief
interventions has improved. In addition, these meta-analyses only
addressed the effect of grief interventions immediately after treatment
completion. Allumbaugh and Hoyt (1999) included controlled but also
non-controlled studies. Currier et al. (2008) analyzed the effect of
controlled bereavement interventions at post-test and follow-up,
included random as well as non-random studies, and investigated
various research questions in their meta-analysis. None of these three
quantitative reviews specifically focused on the effect of bereavement
interventions on (complicated) grief.
Therefore, use of stringent inclusion criteria (such as the inclusion
of only randomized controlled trials, RCT's) and limitation of the
outcome variable to (complicated) grief measures in the current
meta-analysis can contribute to the overall understanding of the
effects of preventive and treatment grief interventions.
The main objective of the current meta-analysis is therefore to
determine the short-term (i.e., immediately after the intervention) and
long-term (i.e., follow-up) effect of specific grief interventions for adults.
Hereby, the aim of the interventions (prevention versus treatment) is
taken into consideration.
2. Method
2.1. Inclusion criteria
We included RCT's in which a specific grief intervention (i.e., an
intervention or technique specifically designed to treat or prevent CG)
was offered to individuals aged 18 years or older who had lost a loved
one through death. This experimental, grief specific, intervention had to
be compared to either a control condition or an a-specific intervention
(i.e., an intervention that is used for a variety of disorders), and
assessments had to include pre- and post- or follow-up-measurements.
A preventive grief intervention is defined as any technique or any more
extensive intervention for bereaved individuals in general designed to
reduce the probability of the development of CG. A treatment grief
intervention is defined as any technique or any more extensive
intervention for bereaved individuals suffering complicated grief
designed to reduce the severity of complicated grief symptoms.
Furthermore, (complicated) grief had to be an outcome variable, to be
measured with a quantitative standardized questionnaire. Only studies
published in a peer-reviewed journal were considered, in order to
provide a degree of quality control in the selection of studies.
Not included were case studies, studies of interventions specifically developed for other loss-related diagnoses than CG, interventions for children, adolescents, caregivers or individuals with
intellectual disabilities as survivors, studies of interventions for loss
of a pet, studies of interventions initiated before the loss (palliative
care), and psychopharmacological interventions.
2.2. Search strategy
Two strategies were used to identify relevant studies. First, the
electronic databases Web of Science (WOS) and PsycArticles were
consulted with the use of the following search terms and Boolean
operators: (bereave* OR mourning OR grief OR survivor OR widow*)
AND (psychotherapy OR therapy OR intervention OR treatment OR
managing OR counselling OR counselling OR support OR help). For Web
of Science the ‘title only’ option was marked, and no refinements for
document types were made. To search PsycArticles, a shortened list of
terms was used (bereavement, bereaved, mourning, grief, survivor, &
widow).
The second strategy consisted of searching eligible studies within
the reference lists of large-scale review articles concerning interventions for the bereaved (these articles are marked with an • in the
reference list of this paper).
As the theoretical basis of the treatment and prevention of grief
and its related concepts has changed considerably during the past
decades, and this study aimed to provide an up-to-date review, only
studies published between 1990 and 2007 were included.
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
2.3. Data analysis
Data were analyzed with REVMAN 5.0.14. A random effect model
was used if heterogeneity was found, while a fixed effect model was
used in case of homogeneity (a p-value of b0.10 for the chi-squared test
for heterogeneity was considered significant). The standardized mean
difference (SMD) was used as the summary statistic in the metaanalysis, because different self-report instruments to measure (complicated) grief ((C)G) were used in the studies (Higgins & Green, 2008).
Since only two studies reported the complete results of intention-totreat analyses, the meta-analysis was performed with outcome data on
study completers.
3. Results
3.1. Identification of studies
After the study selection process (see Fig. 1 for details), 14 studies
met the inclusion criteria (these articles are markes with an * in the
reference list of this paper). Table 1 provides an overview of included
studies, according to aim of intervention (prevention versus treatment),
and characteristics of participants, interventions, trials, and follow-up
periods.
In total, 1655 subjects initially participated in the included studies,
of which 910 were in the specific grief intervention condition and 745
were in the control or a-specific grief intervention condition. A total of
344 subjects was lost to follow-up.
Males were underrepresented in the study groups as an average of
70% was female (range from 0% to 92%). Mean age of participants was
41 years (range from 20 to 57 years). Preventive interventions mostly
targeted high risk groups (such as spouses and suicide survivors) for
CG, while treatment interventions made no differentiations regarding
mode of death or kinship.
With respect to intervention aim, nine studies examined preventive
grief interventions. Three of these studies reported moderately positive
results with regard to (C)G of which two offered a cognitive-behavioral
oriented preventive intervention. Five studies examined treatment grief
71
interventions. Positive results with respect to (C)G were reported in four
of these studies. All of these four treatment interventions employed
cognitive-behavioral techniques. In eight studies the specific grief
intervention was compared with a control condition (of which seven
were preventive interventions and one a treatment intervention) and in
six studies with an a-specific grief intervention (of which four were
treatment interventions). A group format was used in eight studies, while
in the remaining six studies individual therapy sessions were offered.
Number of sessions differed substantially among studies, with one to
twelve sessions in preventive interventions and ten to sixteen sessions in
treatment interventions. All but two studies (both preventive interventions) assessed participants at post-test and in five studies (of which four
were treatment interventions) a follow-up measurement was absent.
A few remarks concerning five studies should be made. Boelen, de
Keijser, van den Hout, and van den Bout (2007) described two different
cognitive-behavioral trials in a cross-over design (cognitive restructuring (CR) + exposure therapy (ET) and ET + CR), which were compared
to a supportive condition. These trials were considered as two separate
studies designated as a (CR + ET) and b (ET + CR). Murphy et al. (1998)
reported results separately for male and female participants, which
were included in the analysis as two separate studies, designated as a
(mothers) and b (fathers). Piper, Ogrodniczuk, Joyce, Weideman, and
Rosie (2007) reported the combined scores on the outcome variables for
the different intervention groups. Upon request the authors kindly
provided their post-data separately for the different intervention
groups. The results of the study of Range, Kovac, and Marion (2000)
were only included in the follow-up analyses, because the number of
participants per group was not reported for post-data and the authors
had no longer access to the required information. Finally, in the study by
Sikkema et al. (2006) follow-up data were provided for three different
time points. The 8-month follow-up data were used to increase
comparability with the follow-up data of the other studies.
3.2. Study quality
Assessment of quality of the included studies was based on the
criteria, which were developed by McDaid, Trowman, Golder, Hawton,
Potentially relevant papers identified through the three
search strategies and screened on the basis of title
(references from reference lists) and on the basis of title
and abstract (WOS & PsycArticles) (n= 806)
Papers excluded due to duplicates, irrelevant subject,
presence of an exclusion criteria, study design (descriptive
studies) (n= 680)
Potentially relevant papers retrieved for more detailed
evaluation (n= 126)
Papers excluded as not meeting the inclusion criteria (n=
7), other reasons for exclusion were absence of a control
group (n= 11), absence of a randomisation procedure (n=
11), descriptive study (n= 24), qualitative or retrospective
study (n= 21), absence of a standardized grief measure or
grief measure could not be used (n= 11), duplicate paper
(n= 19), irrelevant subject (n= 5), unobtainable data (n= 2),
unobtainable publication (n= 1)
Citations included in the meta analysis (n= 14)
Fig. 1. Flow diagram of study selection process.
72
Table 1
Characteristics of participants, interventions, trials, and follow-up periods of the included studies.
Study
Details of participants
Goodkin et al.
(1999)¹
Kovac and Range
(2000)
Lieberman & Yalom
(1992), Yalom &
Vinogradov (1988)
Murphy et al.
(1998)²
Nikčević et al.
(2007)
O'Connor et al.
(2003)
Homosexual HIV-seropositive and HIV-seronegative
men who lost a close friend or intimate partner
to AIDS within the prior 6 months; mean time
since loss not reported; 100% male; 63% Caucasian
& 24% Hispanic American, mean age 38 years
Undergraduate students who lost a loved one
to suicide within the past 2 years; participants
had to be close to the deceased and had to be
upset by the death, mean time since loss 12 months;
79% female, 88% Caucasian, mean age 24 years
Spouses who lost their partner to cancer
within the prior 4 to 10 months; mean time
since loss not reported; 72% female,
100% Caucasian, mean age 57 years
Parents who lost their 12- to 28-year-old
children due to accidents, homicide or suicide
within the prior 2 to 7 months; mean time
since loss 4 months; 65% female, 86% Caucasian,
mean age 45 years
Women who were attending for a routine
scan at 10–14 weeks of gestation and found
to have a missed miscarriage; mean time
since loss not reported; 100% female, 95%
Caucasian, mean age 35 years
Bereaved family members whose relatives
died up to 1 year previously; mean time since
loss 9 months; 71% female; ethnicity not
reported; mean age 57 years
Initial number of participants
(number lost to follow-up)
Post-test
Follow-up period
Experimental: A family based, cognitive behaviour counselling
programme (psycho-education and cognitive restructuring) of 4
sessions (of 2 h) with a trained psychiatric nurse counsellor
between 3 and 6 months after the suicide
134 (12)
No
13 months after
the suicide
197 (31)
Yes
No
42 (12)
Yes
6 weeks
56 (3)
No
1 year after entering
group therapy
261 (45)
Yes
6 months
80 (14)
Yes, 2 weeks after
session
9 weeks
69 (24)
Yes, 2 weeks after
session
6 weeks
Control: care as usual
Experimental: A bereavement support group intervention
(combination of cognitive-behavioral and social support group
interventions, stressor-support-coping model) of 10 weekly
sessions (of 90 min) led by 2 experienced co-therapists
Control: community standard-of-care control condition
Specific: a profound writing condition (Pennebaker's experimental
writing paradigm, participants were asked to write about the events
and emotions surrounding the loss of your loved one, writing about
traumatic events, emotional events) of 4 writing assignments
(of 15 min) over 2 weeks alone at the lab room.
A-specific: a trivial writing condition (participants were asked to
write about a different trivial topic for each assignment, writing
about innocuous topics, objective topics) of 4 writing assignments
(of 15 min) over 2 weeks alone at the lab room
Experimental: A brief group psychotherapy (focus on interpersonal
and existential issues) of 8 weekly group sessions (of 80 min)
led by an experienced male–female co-therapy team.
Control: control condition
Experimental: a preventive broad-spectrum group intervention
(two-dimensional approach, consisted of information-giving
and skill-building support followed by emotion-focused support)
of 10 weekly sessions (of 2 h) led by men-women pairs of group
leader-clinicians who were psychologists, nurses, or family therapist.
Control: a 3-session delayed intervention control condition
Experimental: an individual psychological counselling intervention
(based on the cognitive therapy framework) of 1 session (of 50 min)
after a medical counselling session, 5 weeks after the
diagnosis, offered by a psychologist
Control: control condition with only a medical counselling session
Experimental: a 1-day writing therapy workshop (Pennebaker's
paradigm, participants are supported, rather than guided to develop
a coherent narrative about the death of their loved one, to explore
feelings and to examine positive aspects of the event(s) alongside
negative thoughts and feelings), led by a writing facilitator with
extensive experience in running groups
Control: a delayed intervention control condition
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
Studies regarding the prevention of complicated grief
de Groot et al.
First degree relatives (aged N 15 years) and
(2007)
spouses of suicide victims, bereaved since
2 to 3 months (at study entry); mean time
since loss not reported; 68% female; ethnicity
not reported, mean age 43 years
Interventions
Range et al.
(2000)
Undergraduate students who lost a loved one
to a sudden unintentional accidental or homicidal
death, mean time since loss 14 months; 80% female;
ethnicity not reported; mean age 20 years
Sikkema et al. (2006),
Sikkema, Hansen,
Kochman, Tate, &
Difranceisco (2004)
HIV-positive or AIDS-diagnosed men and women
who lost a loved one to AIDS within the prior
2 years (but not less than 1 month ago); mean
time since loss not reported; 35% female, 54%
African American and 27% Caucasian, mean
age 40 years
Piper et al.
(2007)
Bereaved individuals suffering complicated grief
who lost a loved one at least 3 months ago, mean
time since loss 8.4 years; 79% female, 84% Caucasian,
mean age 45.2 years
Shear et al.
(2005)
Bereaved individuals suffering complicated grief
who lost a loved one to violent or non-violent
causes at least 6 months ago, mean time since
loss not reported (median 2.1 and 2.5 years);
87% female, 53% Caucasian, mean age 48 years
Wagner et al.
(2006)
Bereaved individuals suffering complicated grief
who lost a loved one at least 14 months ago, mean
time since loss 4.6 years; 92% female, ethnicity
not reported, mean age 37 years
Specific: an individual cognitive-behavioral therapy (exposure therapy
& cognitive restructuring) of 12 weekly manual-based sessions
(of 45 min) led by trained therapists
A-specific: an individual supportive counseling intervention (focus
on practical difficulties and problem solving) ) of 12 weekly
manual-based sessions (of 45 min) offered by a trained therapist
Specific: an interpretive, time-limited, short-term group therapy
(focus on enhancement of patients' insight about repetitive conflicts
and trauma that are associated with the losses) of 12 weekly sessions
(of 90 min) led by experienced group therapists
A-specific: a supportive , time-limited, short-term group therapy
(focus on improvement of the patients' immediate adaptation to their
life situations) of 12 weekly sessions (of 90 min)
Specific: an interpretive, time-limited, short-term group therapy
(focus on enhancement of patients' insight about repetitive conflicts
and trauma that are associated with the losses) of 12 weekly sessions
(of 90 min) led by experienced group therapists
A-specific: a supportive , time-limited, short-term group therapy
(focus on improvement of the patients' immediate adaptation to their
life situations) of 12 weekly sessions (of 90 min)
Specific: an individual complicated grief treatment (a form of cognitivebehavioral therapy combined with aspects of interpersonal therapy)
of 16 sessions over a 16- to 20-week period offered by an experienced
and licensed therapist
A-specific: an individual interpersonal therapy (IPT) of 16 sessions over
a 16- to 20-week period offered by an experienced and licensed therapist
Experimental: an internet-based cognitive-behavioral therapy of two
weekly writing assignments (of 45 min) conducted by trained psychologists
Control: delayed intervention control condition/waiting list control condition
64 (20)
Yes
6 weeks
267 (74)
Yes
8 months
54 (15)
Yes
6 months
139 (32)
Yes
No
135 (25)
Yes
No
102 (33)
Yes
No
55 (4)
Yes
No
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
Studies regarding the treatment of complicated grief
Boelen et al.
Bereaved individuals suffering complicated grief
(2007)
who lost a loved one to violent and non-violent
causes at least 2 months ago (this was during the
study changed to 6 months), mean time since loss
45 months; 74% female, ethnicity not reported,
mean age 44 years
Piper et al.
Bereaved individuals suffering complicated grief
(2001)
who lost a loved one (cause of death not reported)
at least 3 months ago, mean time since loss 9 years;
77% female, 90% Caucasian, mean age 43 years
Specific: profound writing condition (Pennebaker's paradigm,
participants were asked to write about the events and emotions
surrounding the loss of their loved one) of 4 daily writing
assignments (of 15 min) alone at the lab room
A-specific: trivial writing condition (participants were asked to
write about a different trivial topic for each assignment) of 4 daily
writing assignments (of 15 min) alone at the lab room.
Experimental: a cognitive-behavioral group intervention (combined
elements of cognitive theory of stress and coping with models of
coping with grief and bereavement) of 12 weekly sessions (of 90 min)
led by 2 experienced co-therapists.
Control: minimal treatment condition (individual therapy (up to
12 sessions) on request comparison condition) (individual mental health
and psychiatric services outside the project protocol on request and
whenever needed)
73
74
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
and Sowden (2008) using three tools: the Centre for Reviews and
Dissemination's guidance for undertaking systematic reviews (Khan, ter
Riet, Glanville, Sowden, & Kleijnen, 2001), a report on evaluating nonrandomised studies (Deeks et al., 2003), and the Quality Assessment
Tool for Quantitative Studies (Effective Public Health Practice Project,
2003).
For seven of the 14 included studies the procedure of assignment to
study arms was described (Goodkin et al., 1999; Shear, Frank, Houck, &
Reynolds, 2005; Sikkema et al., 2006; Wagner, Knaevelsrud, & Maercker,
2006; Boelen et al., 2007; de Groot et al., 2007; Nikčević, Kuczmierczyk,
& Nicolaides, 2007). In the remaining studies the authors did not
explicitly report the assignment procedure (Lieberman & Yalom, 1992;
Murphy et al., 1998; Kovac & Range, 2000; Range et al., 2000; Piper,
McCallum, Joyce, Rosie, & Ogrodniczuk, 2001; O'Connor, Nikoletti,
Kristjanson, Loh, & Willcock, 2003; Piper et al., 2007). The method of
randomisation was described in six studies (Goodkin et al., 1999; Shear
et al., 2005; Wagner et al., 2006; Boelen et al., 2007; de Groot et al., 2007;
Nikčević et al., 2007). Concealment of treatment allocation was secured
in three studies (Goodkin et al., 1999; Shear et al., 2005; Nikčević et al.,
2007). In one study an attempt at concealment was made (de Groot et
al., 2007). For the remaining studies it was unclear whether treatment
allocation was concealed (Lieberman & Yalom, 1992; Murphy et al.,
1998; Kovac & Range, 2000; Range et al., 2000; Piper et al., 2001;
O'Connor et al., 2003; Sikkema et al., 2006; Wagner et al., 2006; Boelen
et al., 2007; Piper et al., 2007).
The experimental and control groups were balanced with regard to
potential confounds in eight studies (Murphy et al., 1998; Piper et al.,
2001; O'Connor et al., 2003; Shear et al., 2005; Wagner et al., 2006;
Boelen et al., 2007; Nikčević et al., 2007; Piper et al., 2007). Of the five
studies in which imbalances among study groups at baseline were
reported (Lieberman & Yalom, 1992; Kovac & Range, 2000; Range et al.,
2000; Sikkema et al., 2006; de Groot et al., 2007), one reported adequate
adjustment for baseline differences (de Groot et al., 2007). For one study
it was not reported if the study groups were balanced for potential
confounds, but adjustments for possible imbalances were made
(Goodkin et al., 1999). Proportion of study completion varied between
65% (O'Connor et al., 2003) and 95% (Lieberman & Yalom, 1992). There
was great variability among the studies regarding sample size, ranging
from 42 (Kovac & Range, 2000) to 267 participants (Sikkema et al.,
2006). All studies used subjective outcome measures to assess (C)G.
These data collection tools were known or shown to be reliable and valid
in all but one study (Range et al., 2000). Intention-to-treat (ITT) analyses
were performed and reported in three studies (performed on total
randomization sample) (Piper et al., 2001; Shear et al., 2005; Boelen et
al., 2007).
A majority of studies (n = 11) reported the use of a treatment
protocol or manual (Murphy et al., 1998; Goodkin et al., 1999; Kovac &
Range, 2000; Range et al., 2000; Piper et al., 2001; Shear et al., 2005;
Sikkema et al., 2006; Wagner et al., 2006; Boelen et al., 2007; de Groot et
al., 2007; Piper et al., 2007). In the remaining three studies treatment
content was described (Lieberman & Yalom, 1992; O'Connor et al., 2003;
Nikčević et al., 2007). In half of the studies (n = 7) an assessment of the
intervention consistency was reported (Lieberman & Yalom, 1992;
Goodkin et al., 1999; Kovac & Range, 2000; Range et al., 2000; O'Connor
et al., 2003; Wagner et al., 2006; Nikčević et al., 2007).
3.3. Meta-analyses
3.3.1. Preventive interventions
The meta-analysis of the interventions aiming at prevention of CG
yielded a pooled standardized mean difference (SMD) of −0.03 (95%
CI: −0.18−0.11; Z = 0.47; p = 0.64) at post-test and of 0.13 (95% CI:
−0.08−0.33; Z = 1.21; p = 0.23) at follow-up. With regard to the
outcome variable, studies were homogeneous in the post-test analysis
(p = 0.12) and heterogeneous in the follow-up analysis (p = 0.07).
The difference among the pooled SMD's of preventive interventions at
post-test and at follow-up was not significant (χ² = 2.41; df = 1;
p = 0.12). Heterogeneity among the studies was found (p = 0.03) (see
Fig. 2).
3.3.2. Treatment interventions
The meta-analysis of the interventions aiming at treatment of CG
yielded a pooled SMD of −0.53 (95% CI: −1.00−−0.07; Z = 2.23;
p = 0.03) at post-test and of −1.38 (95% CI: −2.08 to −0.68; Z = 3.87;
p = 0.0001) at follow-up. With respect to the outcome variable, studies
were heterogeneous (p = 0.009) in the post-test analysis and homogeneous (p = 0.87) in the follow-up analysis. The difference of the pooled
SMD's among post-test and follow-up of treatment interventions was
significant in favor of the effect at follow-up (χ² = 8.65; df = 1;
p = 0.003). Heterogeneity among the studies was found (p = 0.0001)
(see Fig. 3).
3.3.3. Prevention versus treatment
The difference among the pooled SMD's of preventive and treatment
interventions at post-test was significant in favor of treatment
interventions (χ² = 3.71; df= 1; p = 0.05). Heterogeneity among the
studies was found (p = 0.0006) (see Fig. 4). The difference among the
pooled SMD's of preventive and treatment interventions at follow-up
was significant in favor of the treatment interventions (χ² = 17.09;
df = 1; p b 0.0001). Heterogeneity among the studies was found
(p = 0.0005) (see Fig. 5).
4. Discussion
Results of this meta-analysis of prevention and treatment studies of
CG among persons who were bereaved through death of a loved one can
be summarized as follows. The results from preventive grief intervention studies provide inconsistent support for their effectiveness. The lack
of a significant effect of preventive interventions on (C)G observed
immediately after the intervention evolves to a rather negative, though
also non-significant effect at follow-up. Treatment interventions, on the
other hand, appear to be efficacious in the short-term and long-term
alleviation of CG symptoms. Contrary to preventive interventions, the
positive effect of treatment interventions increases significantly over
time.
Prior to a discussion of the implications of these findings for
prevention and treatment of CG some methodological limitations
have to be addressed. First, at the moment CG is not recognized as an
official (DSM-) diagnosis. Nevertheless, CG-symptoms have shown to
be different from other symptoms and disorders, such as normal grief
reactions (Boelen & van den Bout, 2008; Dillen et al., 2008), mood
disorders (Boelen & van den Bout, 2005; Bonanno et al., 2007;
Lichtenthal et al., 2004; Silverman et al., 2000), and anxiety disorders
(Boelen & van den Bout, 2005), such as Post Traumatic Stress Disorder
(PTSD) (Bonanno et al., 2007; Lichtenthal et al., 2004; Silverman et al.,
2000). These findings were corroborated across different subgroups of
mourners, e.g., violent and non-violent deaths, male and female
survivors (Boelen & van den Bout, 2005, 2007). Moreover, the same
set of criteria is indicative for CG irrespective of time since loss
(Boelen & van den Bout, 2007).
Second, due to ethical reasons not all included studies used a nonintervention control group, and some of the bereavement interventions
were compared to more general (a-specific) interventions. In this context
it is important to note that Allumbaugh and Hoyt (1999) found no
difference in effect size among studies using ‘placebo’ treatment groups
and control groups.
Third, this meta-analysis of bereavement interventions investigated
the effect of interventions on CG. The performed analyses could thus have
yielded different results with other outcome measures. For instance, Piper
et al. (2001), compared interpretive therapy (specific grief therapy) to
supportive therapy (non-specific grief therapy), and observed a similar
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
75
Fig. 2. Short term and long term effect of preventive interventions on (complicated) grief.
effect size for both study groups with respect to CG, while interpretive
therapy yielded a larger effect size concerning anxiety and depression.
Fourth, only a small number of papers were available for this metaanalysis, which is due to the use of stringent inclusion criteria and
data sources (for example, gray literature was not searched).
Fifth, there were differences among the preventive and treatment
interventions concerning the instruments to assess (C)G. The
preventive interventions often utilized general grief measures, while
the treatment interventions assessed CG. Therefore, the comparability
of the results of both interventions is limited.
Sixth, preventive interventions mostly focused on specific risk groups
for the development of CG (such as parents, suicide survivors, and
widows), but used general grief measures. Such measurements may not
have been sufficiently sensitive to adequately represent grief reactions
after a specific loss (e.g., kinship and mode of death). For example, in a
study with students who lost a loved one to suicide, no significant
difference was observed among the study groups with respect to general
grief, contrary to suicidal grief (Kovac & Range, 2000).
Seventh, it is important to note that only one study (Boelen et al.,
2007) examined the long-term effect of treatment interventions on
Fig. 3. Short term and long term effect of treatment interventions on complicated grief.
76
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
Fig. 4. Difference in short term effect of preventive and treatment interventions on (complicated) grief.
CG, in which two specific treatment groups were compared to a
supportive counselling group. For the current analysis, this single
study was divided in two separate studies, which could possibly have
biased the reliability of the result.
Eighth, studies in this meta-analysis investigated consequences of
deaths due to a wide range of violent and non-violent causes, but may
not have included deaths due to particular circumstances such as
military service. Further study is needed to investigate effects of
interventions following death due to such circumstances.
Finally, 70% of study participants in the included studies are female.
The predominance of females may be due to a number of factors including
a comparatively greater effect of loss (Stroebe et al., 2007), a more
common perception that help is useful (De Groot, Van der Meer, & Burger,
2009), and more help seeking behavior (Stead, Shanahan, & Neufeld,
2010) among women than men. The predominant representation of
females in the studies may limit the generalization of results to men.
It is not clear whether differences among interventions can be
attributed to the interventions. More particularly, lack of effect of
preventive interventions as demonstrated in this review may be due to,
first, the interventions per se, second, to the problem of complicated
grief, or, third, to other factors including characteristics of study
participants and other types of support received by participants. First,
Fig. 5. Difference in long term effect of preventive and treatment interventions on (complicated) grief.
C. Wittouck et al. / Clinical Psychology Review 31 (2011) 69–78
the lack of effect of preventive interventions can theoretically be due to
the fact that some interventions may show impressive effectiveness
while others may show little benefit or even negative effects. This
review has shown that effects of preventive interventions indeed may
be positive or negative, though all but one not significant. Negative
outcomes may thereby be due to improved adjustment among
participants not receiving the intervention, while positive outcomes
may be due to deterioration among controls. Based on their review,
Neimeyer and Currier (2009) could however not find any support for
the latter interpretation.
Second, demonstrated lack of effect of preventive interventions may
be due to the possibility that prolonged grief cannot be prevented, which
is supported by the finding that interventions aiming at (primary)
prevention have no effect on the outcome among people who suffered a
loss (Neimeyer & Currier, 2009).
Third, characteristics of study participants may have influenced
the outcome of this review. While factors such as gender, age and
relationship to the deceased may not have such an effect (Neimeyer &
Currier, 2009), study participants may have constituted subgroups
based on unidentified other moderating characteristics, which may
respond differently to different interventions.
Despite these limitations, the results of this meta-analysis offer a
quantification of earlier and rather qualitative findings regarding grief
interventions. The findings confirm the proposition that professional
assistance is indicated for only a subgroup of the bereaved, namely
those who show (the onset of) CG reactions (Jacobs & Prigerson, 2000;
Neimeyer, 2000; Schut et al., 2001; Jordan & Neimeyer, 2003;
Bonanno et al., 2004; Schut & Stroebe, 2005; Stroebe et al., 2007).
Prigerson et al. (1997) conclude: “it may not be the stress of
bereavement per se that puts individuals at risk for long-term mental
and physical health impairments. Rather, it appears that the
manifestation of psychiatric sequelae, specifically traumatic grief, is
of critical importance” (p. 622).
In addition, our results suggest that CG can be treated but not
prevented. This does however not necessarily mean that interventions
aimed at the prevention of CG do not have any value. First, the absence
or limited effects of preventive grief interventions does not necessarily
reflect a lack of effect at an individual level. Measures of improvement
often are quantitative measures of (C)G, anxiety, and depression, and
the effect of preventive grief interventions may not be situated in these
areas, but rather on a qualitative level, such as feeling supported in their
mourning process by co-mourners or a grief counsellor. Currier et al.
(2008) point out the importance of assessing protective factors (as
coping skills) and practical benefits (as reducing health-care costs) over
several years in studies focusing on preventive interventions.
Second, if bereaved individuals feel the need for grief counselling
(either individually or in group), irrespective of whether their grief
reactions are to be regarded as normal or complicated, they may very
well benefit from a counselling program. A preventive intervention
study by Kang and Yoo (2007), which was not included in this metaanalysis due to the absence of randomisation, indeed provides support
for this assumption. Participants were allowed to choose themselves
to which study arm (bereavement group versus control condition)
they were assigned. Bereavement group participants significantly
improved over time in comparison with control group participants on
the grief scale. This was not the case in the preventive studies included
in the current analysis.
Third, preventive interventions may accelerate the adjustment process
after a significant loss (Currier et al., 2008).
Fourth, the finding that the results of preventive intervention studies
reveal inconsistent support for their effectiveness may be due to the
possibility that such studies are more problematic to conduct.
Finally, it should be noted that the preventive grief interventions
often were techniques rather than comprehensive interventions.
Further study into the treatment and prevention of CG is needed.
First, although interventions aimed at the treatment of CG appear to
77
be effective, effect sizes may be smaller than those of treatments for
other psychiatric disorders (Allumbaugh & Hoyt, 1999). The aim of CG
treatment is to adjust CG reactions into normal grief reactions, which
are themselves almost always accompanied by some kind of distress
and therefore result in higher scores on self-report measures. Second,
the most adequate treatment for CG may not have been developed
yet. According to O'Connor et al. (2003), a universal treatment for CG
may not exist as grief can be viewed as a multidimensional construct
(O'Connor et al., 2003). An integrative risk factor framework for the
prediction of bereavement outcome is described by Stroebe, Folkman,
Hansson, and Schut (2006). In this model it is postulated that
adaptation to bereavement is influenced by bereavement-related
stressors (loss-oriented stressors such as type of loss and mode of
death, and restoration-oriented stressors such as work problems and
economic changes), appraisal and coping (cognitive-behavioral
processes and mechanisms, emotion regulation and oscillation
between confrontation and avoidance of bereavement-related stressors), interpersonal risk factors (these factors originate within the
social or environmental context and are external to the bereaved
person, such as social support, intervention programs and family
dynamics), intrapersonal risk factors (these factors are intrinsic to the
bereaved person, such as sociodemographic variables, personality,
attachment style, and predisposing vulnerabilities) and by interactions among these risk factors (Stroebe et al., 2006). Thus, each person
may grieve in a unique way. Therefore treatment protocols may have
to be adaptable to individual needs. Third, the aim and content of
preventive interventions should be reconsidered, and outcome
measures of general grief should be refined considering background
variables as kinship and mode of death.
Results of this meta-analysis clearly point at a difference among
the short-term and long-term effects of preventive and treatment
strategies for CG, in favor of the latter. Recent treatment interventions
for CG have been designed more adequately and have proved to be
efficacious. Nevertheless, taking into account the common prevalence
of potentially devastating consequences of CG, treatment studies
should be replicated using larger samples and long-term follow-up
periods.
Acknowledgement
This study was supported by a grant from “Go for Happiness”.
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