Some people, counsellors and clients alike, would argue (unjustifiably in my view) that even asking the question, with its implicit assumption that it might not work, is a form of heresy.
“Of course it works!” the counsellor will cry, “I can give you countless examples from my practice where grateful clients have said how much it has helped them”.
Practically any bereavement service can produce evidence from evaluations, that clients believe it to be effective. Indeed some services have even cited such feedback in academic journals (See for example, Gallagher, Tracey, & Millar, 2005). In the service where I work, last year 100% of our clients who returned evaluations, would recommend our service to others. It seems self-evident that bereavement counselling works.
Yet let me ask you a very simple question: How do you know for certain, that without counselling, your client would not equally well have come to terms with their loss, would not have learnt to cope with the absence of the lost loved-one? The reality is that most people do not present for counselling following bereavement. As time passes, people generally do find ways towards a satisfactory level of grief resolution. Individuals may continue to grieve quietly, especially around anniversaries, for the rest of their lives, but on a day to day basis they cope adequately. Had they received counselling, it could well have been an illusion that it was this that helped.
If we are really serious about evidence-based practice, we must be prepared to submit our practice to scientific scrutiny. The most rigorous test is usually perceived to be the randomized controlled trial. Medication must pass such tests, so why not counselling? Although some talking therapies specific to bereavement have stood the test (See for example, Shear, Frank, Houck, & Reynolds, 2005), many other studies have suggested that bereavement counselling is often ineffective. As Henk Schut and colleagues put it:
“A substantial number of grief intervention efficacy studies have resulted in disappointing, sometimes even negative, results.” (Schut, Stroebe, van den Bout, & Terheggen, 2001, p. 705).
Jordan and Neimeyer (2003) even cited Neimeyer’s work with Fortner (Fortner & Neimeyer, 1999) which suggested that a significant number of bereaved people would do better without professional intervention. This claim received widespread publicity at the time, although Larson and Hoyt (2007) have questioned the reliability of this finding. Nonetheless, the overwhelming evidence suggests that bereavement counselling is of limited efficacy. Schut and colleagues (2001, p.731) concluded that the more complex the grieving person’s needs, the more likely that counselling will be effective. On the other hand, routinely offering professional support for normal grief shows no benefit, and interventions for moderate levels of grief may only have a temporary ameliorative effect.
So what should grief counsellors make of this? Should we just accept our theoretical uselessness, pack up and go home? Should we look more carefully at the evidence and seek explanations? Should we pick and choose our research: ignore the negative and be bolstered by the positive, then carry on regardless on the basis that ignorance is bliss? Where does our professional responsibility lie? I think that you know the answer.
I can identify with the finding that self-referring clients who own their need, have better outcomes than those referred routinely. When at assessment, a client begins by saying “I’m here because my doctor thinks it’s a good idea”, I reply “So what do you think?” Unenthusiastic responses to my question are a good predictor of poor counselling outcomes. The bereaved client who owns her need and identifies her goals is the client who does best in my experience (That assertion is anecdotal at the moment, but part of my current research). If you want an evidence base for this assertion, I recommend Cooper (2008) and Bohart and Tallman (1999).
There is also a philosophical point to be made, and it is this. Just because counselling cannot be proved to work, doesn’t mean that it doesn’t. For all sorts of reasons, methodological and ethical, it is difficult to conduct experiments to demonstrate bereavement counselling efficacy. Ethically, we must have our client’s informed consent to study them. In my research experience, the most distressed clients are the once least likely to give consent. Some who do volunteer to be studied closely are fascinated by the therapeutic process, hence are more likely to be psychologically minded and thus more like to engage effectively in the therapy. Methodologically, how do we arrive at a control group without denying counselling to some (unethical) or by extending the waiting time (unethical)? If we investigate the grief reaction in our control group, might the process of investigating and measuring in itself, be therapeutic? How do we produce small but matched experimental samples, given the uniqueness of each person’s grief? None of this means that we should not strive to seek answers; simply that it is difficult to do so, and that we should be careful in our interpretation.
And this brings me to my next point. Even if bereavement counselling is of limited effectiveness, should we leave distressed and lonely people to fend for themselves? As Robert Neimeyer illustrates in his workshops, if we see an injured person in the street it is right to comfort and tend the injury, regardless as to whether ultimately it speeds her healing. Extending this analogy, treatment for some of her injuries might be painful and distressing, making her feel worse in the short term, but with ultimate benefits. Clients emotionally injured by loss may feel worse before they feel better, particularly where their grief has been ‘bottled up’. I am under no illusions that some clients would ultimately manage to come to terms with loss without my help. However it would be heartless to deny support and leave them emotionally and physically isolated from caring human contact. I should stress that this contact does not necessarily need to be from counselling. By the same token, grieving clients with complicated circumstances and complex issues to contend with, may never satisfactorily resolve their grief without skilled professional intervention. This accords with the research findings cited above.
Conclusions and professional implications – my own view
We have a professional duty to be guided by evidence-based practice.
All clients should be assessed to see if their needs can be met by the service which is offered.
Clients grieving healthily, without complex issues and complicating circumstances surrounding the loss, should also be assessed for levels of social support versus isolation. This group should be given the choice of support, even if objectively, it may ultimately make no difference. However, these clients should be told that their grief is normal and natural, so that their choice to receive support is an informed one. In my experience, many people feel reassured at this point, are glad that they came for the assessment, and elect not to continue. Financially exploiting clients is unethical.
All clients should be warned that they may feel worse before they feel better, and if this happens, urged to talk to their counsellor. Stopping counselling is unlikely to be the answer.
Clients whose grief is complicated by circumstances, is prolonged, or has resulted in depressive symptoms and who have self-referred, should be advised that counselling could help, even that it is likely to help, although it is unethical to make promises that it will definitely help. No practitioner should work beyond her or his level of competence.
A note to referrers
Empirical evidence suggests that clients who self-refer to bereavement counselling do better that those who are sent with a professional referral. Whenever possible, furnish your client/patient with the bereavement counsellor’s contact details and leave the rest to your patient. If they do not refer themselves, this is a measure of their readiness to do the work and an indicator that the work would not be effective.
References
Bohart, A. C., & Tallman, K. (1999). How Clients Make Therapy Work: The Process of Active Self-healing. Washington DC: American Psychological Association.
Cooper, M. (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. London: Sage.
Fortner, B. V., & Neimeyer, R. A. (1999). Paper presented at the Annual meeting of the Association for Death Education and Counseling, San Antonio, Texas.
Gallagher, M., Tracey, A., & Millar, R. (2005). Ex-clients’ evaluation of bereavement counselling in a voluntary sector agency. Psychology and Psychotherapy, 78(1), 59-76.
Jordan, J. R., & Neimeyer, R. A. (2003). Does grief counseling work? Death Studies, 27(9), 765-786.
Larson, D. G., & Hoyt, W. T. (2007). What has become of grief counseling? An evaluation of the empirical foundations of the new pessimism. Professional Psychology: Research and Practice, 38(4), 347-355.
Schut, H., Stroebe, M. S., van den Bout, J., & Terheggen, M. (2001). The Efficacy of Bereavement Intervention: Determining Who Benefits. In M. S. Stroebe, R. O. Hansson, W. Stroebe & H. Schut (Eds.), Handbook of Bereavement Research: Consequences, Coping and Care (pp. 705-737). Washington DC: American Psychological Association.
Shear, M. K., Frank, E., Houck, P. R., & Reynolds, C. F. (2005). Treatment of complicated grief: a randomized controlled trial. Journal – American Medical Association, 293(21), 2601-2608.