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January 27, 2004
Often, Time Beats Therapy for Treating Grief By JANE E. BRODY
It is commonly assumed in this therapy-oriented world that nearly every grieving person can benefit from bereavement counseling or therapy. But both the experience of psychologists who provide bereavement services and a thorough review of the literature on the results of grief therapy suggest otherwise.
Rather, the findings suggest, a majority of people who suffer the loss of a loved one neither need nor benefit from participation in a bereavement group or from more formal grief therapy. These people experience what might be called a normal grief reaction, and the symptoms of it gradually diminish over 6 to 18 months.
"Feeling grief is the burden we face because we're capable of becoming attached and loving people," said Dr. Robert Hansson, a psychologist and student of grief at the University of Tulsa. "It's a natural process. It hurts, but most people can work through it and go on."
A major new "Report on Bereavement and Grief Research" prepared by the Center for the Advancement of Health concluded, "A growing body of evidence indicates that interventions with adults who are not experiencing complicated grief cannot be regarded as beneficial in terms of
diminishing grief-related symptoms."
The report adds that there is very little evidence for the effectiveness of interventions like crisis teams that visit family members within hours of a loss, self-help groups that seek to foster friendships, efforts to show the bereaved ways to work through grief and a host of other therapeutic approaches believed to help the bereaved.
In fact, the studies indicate, grief counseling may sometimes make matters worse for those who lost people they loved, regardless of whether the death was traumatic or occurred after a long illness, according to Dr. John Jordan, director of the Family Loss Project in the Boston area. Such people may include the only man in a group of women, a young person in a group of older people, or someone recently bereaved in a group that includes a person still suffering intensely a year or more after the loved one's death.
Further, the research suggests, bereavement counseling is least needed in the immediate aftermath of a loss. Yet it is then that most grieving people are invited to take part in the offered services. A more appropriate time is 6 to 18 months later, if the person is still suffering intensely.
Even when bereavement therapy is needed, however, the benefit may depend on the approach used.
For example, most bereavement groups focus on emotional issues. These are most helpful to women. But men tend to grieve differently, and they are more likely to benefit from an approach that focuses on their processes of thinking.
Caring friends and relatives often coax those who have just suffered the loss of a loved one to seek professional help, either by taking part in a bereavement group or through individual psychotherapy.
But Dr. Robert A. Neimeyer, professor of psychology at the University of Memphis, editor of the scientific journal Death Studies and chairman of the committee that prepared the new report, said in an interview: "Not everyone requires the same thing. Dealing with grief is not a `one size fits all' proposition."
Dr. George Bonanno, psychologist at Columbia's Teachers College, has found that the bereaved who naturally avoid emotions should not be forced to confront grief. Even three years later, such people show no traumatic consequences as a result of suppressing it, he reported.
In more than half the cases, Dr. Neimeyer explained, far more useful than therapy to the bereaved are the empathy and emotional and physical support that friends, relatives and caring people in the neighborhood and at work can provide in the first weeks and months after a death.
Only when grieving is "complicated" - intense and protracted, associated with deep unrelieved depression and interfering with normal enjoyments, life tasks or an ability to work - is there a clear-cut need for grief therapy, Dr. Neimeyer said.
Dr. Hansson of Tulsa observes that many people who experience complicated grief have neither faced their losses nor allowed themselves to work through the emotions that naturally ensue.
If, months down the road, a bereaved person is still grieving intensely, therapy should be sought, Dr. Neimeyer said. Among the hallmarks of complicated grief he listed are "intrusive thoughts about the deceased, recurrent images of how the person died, a continual quest to reconnect with the deceased, corrosive loneliness, feeling purposeless and empty, difficulty believing the death ever happened and feeling that the world cannot be trusted.
Treating people with these symptoms is important because their unresolved grief can have serious, even life-threatening health consequences, including high blood pressure, stroke, heart attack, substance abuse and suicide. "Such people can literally die of a broken heart," Dr. Neimeyer said.
Perhaps the most revealing study of the varying courses of bereavement was undertaken by Dr. Bonanno, Dr. Camille B. Wortman, a psychologist at the State University of New York at Stony Brook, and six co-authors.
They evaluated 1,532 people (all married, with at least one partner of each couple over age 65), then followed them for up to eight years. When a spouse died, they assessed the bereavement experiences of the widow or widower over time. This is what they found:
Forty-six percent of the survivors were "resilient." They experienced transitory distress, but scored low in depression both before the death and at 6 and 18 months after losing their spouses.
Eleven percent followed a common grief course, with rather severe depression at 6 months that had largely disappeared by 18 months.
Sixteen percent, who were not initially depressed, nonetheless were devastated afterward, experiencing prolonged depression.
Eight percent were chronically depressed beforehand, with the depression worsened by the death.
But 10 percent who had been depressed before the death did very well afterward, perhaps because they had been in bad marriages or were relieved from the burdens of taking care of ill spouses.
The remaining 9 percent did not fit into any category.
No Single Pathway
"Clearly," Dr. Neimeyer said, "the five stages of grief - denial, anger, bargaining, depression and acceptance - don't necessarily fit. There is no one pathway through grief. Depending on their grief reaction, people may require very different therapy or no therapy at all."
Also new are professional beliefs about the goals of resolving one's grief, which traditionally focused on forgetting the loss and moving on.
"We are less wedded to seeking closure, to the idea of saying goodbye to the one who died," Dr. Neimeyer said. "We now recognize the importance of finding healthy ways to sustain a relationship with a deceased loved one, to maintain continuing healthy bonds, for example, by carrying forth their projects.
"Closure is for bank accounts, not for love accounts. Love is potentially boundless. The fact that we love
one person doesn't mean we have to withdraw love from another."
Copyright 2004 The New York Times Company