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Effectiveness of bereavement counselling through a community‐based organization: A naturalistic, controlled trial

Authors:
  • Utrecht University & University of Groningen

Abstract

This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling model for adults on reducing complicated grief (CG) symptoms. Participants (N = 344; 79% female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was hypothesized that participants who received intervention would experience a greater decline in CG levels immediately following the intervention compared to the control participants, but the difference would diminish at follow‐up (due to relapse). Data were collected via postal questionnaire at 3 time points: baseline (T), post‐intervention (T + 12 months), and follow‐up (T + 18 months). CG, post‐traumatic stress, and general psychological distress were assessed at all time points. Multilevel analyses controlling for relevant covariates were conducted to examine group differences in symptom levels over time. A stepwise, serial gatekeeping procedure was used to correct for multiple hypothesis testing. A main finding was that, contrary to expectations, counselling intervention and control group participants experienced a similar reduction in CG symptoms at postmeasure. However, intervention participants demonstrated a greater reduction in symptom levels at follow‐up (M = 53.64; d = .33) compared to the control group (M = 62.00). Results suggest community‐based bereavement counselling may have long‐ term beneficial effects. Further longitudinal treatment effect investigations with extensive study intervals are needed.
RESEARCH ARTICLE
Effectiveness of bereavement counselling through a
communitybased organization: A naturalistic, controlled trial
Catherine Newsom
1
|Henk Schut
1
|Margaret S. Stroebe
1,2
|Stewart Wilson
3
|
John Birrell
3
|Mirjam Moerbeek
4
|Maarten C. Eisma
2
1
Department of Clinical Psychology, Utrecht
University, Utrecht, The Netherlands
2
Department of Clinical Psychology and
Experimental Psychopathology, University of
Groningen, Groningen, The Netherlands
3
Cruse Bereavement Care Scotland, United
Kingdom
4
Department of Methodology and Statistics,
Utrecht University, Utrecht, The Netherlands
Correspondence
Catherine Newsom, Department of Clinical
Psychology, Utrecht University, P.O. Box
80140, 3508 TC Utrecht, The Netherlands.
Email:c.e.newsom1@uu.nl
Funding information
Utrecht University's Linschoten Institute for
Psychological Research
This controlled, longitudinal investigation tested the effectiveness of a bereavement counselling
model for adults on reducing complicated grief (CG) symptoms. Participants (N= 344; 79%
female; mean age: 49.3 years) were adult residents of Scotland who were bereaved of a close
relation or partner, experiencing elevated levels of CG, and/or risks of developing CG. It was
hypothesized that participants who received intervention would experience a greater decline
in CG levels immediately following the intervention compared to the control participants, but
the difference would diminish at followup (due to relapse). Data were collected via postal ques-
tionnaire at 3 time points: baseline (T), postintervention (T + 12 months), and followup
(T + 18 months). CG, posttraumatic stress, and general psychological distress were assessed
at all time points. Multilevel analyses controlling for relevant covariates were conducted to
examine group differences in symptom levels over time. A stepwise, serial gatekeeping proce-
dure was used to correct for multiple hypothesis testing. A main finding was that, contrary to
expectations, counselling intervention and control group participants experienced a similar
reduction in CG symptoms at postmeasure. However, intervention participants demonstrated
a greater reduction in symptom levels at followup (M=53.64; d=.33) compared to the control
group (M=62.00). Results suggest communitybased bereavement counselling may have long
term beneficial effects. Further longitudinal treatment effect investigations with extensive study
intervals are needed.
KEYWORDS
bereavement, complicated grief, counselling, grief, prolonged grief disorder
1|INTRODUCTION
Research and professional consensus suggest that the majority of
bereaved people will cope with the pain of a normalgrief reaction
without professional help, and that, over time, they will begin to
feel better (Kersting, Brähler, Glaesmer, & Wagner, 2011; Zisook
et al., 2014). Still, bereavement is associated with a variety of neg-
ative mental and physical health outcomes (for reviews: Stroebe,
Schut, & Stroebe, 2007; Zisook et al., 2014). Physical health out-
comes include an increased risk of mortality (Buckley et al., 2012),
suicidality (Prigerson et al., 1997; Zisook et al., 2014), and morbidity
(Buckley et al., 2012; Keyes et al., 2014; O'Connor, SchultzeFlorey,
Irwin, Arevalo, & Cole, 2014). Mental health outcomes include
depression, posttraumatic stress disorder (PTSD), and difficulties
in grieving that extend in duration and severity beyond the scope
of normalgrief symptoms, also termed complicated grief (CG)
(Zisook et al., 2014). For the sake of clarity, it is useful to note that
varying labels and definitions of CG have been proposed (e.g.,
prolonged grief disorder, persistent complex bereavement disorder;
American Psychiatric Association, 2013; Maercker et al., 2013;
Prigerson et al., 2009; Shear, 2015), with estimates of the preva-
lence and incidence of CG varying according to the definition and
the population observed (for a brief review, see Rosner, Pfoh, &
Kotoučová, 2011).
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This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2017 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.
Received: 8 February 2017 Revised: 14 June 2017 Accepted: 20 June 2017
DOI: 10.1002/cpp.2113
O1512 Clin Psychol Psychother. 2017;24:O1512O1523.wileyonlinelibrary.com/journal/cpp
Given the patterns of difference in reactions to a loss experience, it
is critically important that effective psychological interventions are
developed for people experiencing difficulties in coping with bereave-
ment. Systematic reviews, including metaanalyses, have identified
the following characteristics of bereavement intervention programs
that have been associated with intervention outcomes: (a) time since
bereavement (interventions early after bereavement appear to be inef-
fective, cf. Bonanno, 2005; Currier, Neimeyer, & Berman, 2008; Schut,
Stroebe, van den Bout, & Terheggen, 2001); (b) the way contact
between client and counsellor is established (outreaching intervention
being related to less positive effects than intervention instigated by
the bereaved person; see Schut et al., 2001); and (c) the initial level of
distress of the bereaved person and risk factors for experiencing com-
plications grieving. Concerning the latter set of characteristics, it has
been demonstrated that higher distress correlates with better results
(cf. Prigerson & Jacobs, 2001; Shear, 2015; Zisook et al., 2014). Inter-
ventions aimed at treating bereaved people with high levels of grief
related distress have been termed tertiary interventions and have been
associated with positive outcomes (Schut et al., 2001). Outcomes for
interventions focused on treating bereaved people with risk factors
for developing complications, termed secondary interventions, have
produced conflicting results (Schut et al., 2001). Nevertheless, recent
investigations where participants were screened for risk factors have
indicated better results for higher risk groups (see Burke & Neimeyer,
2013; Litz et al., 2014; Shear, 2015).
It can be surmised that an effective intervention would be aimed
specifically at helpseeking bereaved people at least 6 months after
bereavement who present with, or are seriously at risk of developing,
psychopathology (Center for the Advancement of Health, 2003;
Currier et al., 2008; Schut et al., 2001; Wimpenny et al., 2007). In line
with these findings, metaanalysis showed that psychotherapeutic
interventions yield moderate effect sizes in helpseeking bereaved
people with elevated levels of grief or CG more than 6 months after
loss (Wittouck, Van Autreve, De Jaegere, Portzky, & van Heeringen,
2011; for examples of effective interventions: Boelen, de Keijser, van
den Hout, & van den Bout, 2007; Shear & Shair, 2005).
Several recent randomized trials of psychotherapy for CG similarly
yield moderate to strong effects when targeting indicated groups of
bereaved people (e.g., Eisma et al., 2015; Litz et al., 2014; Rosner, Pfoh,
Kotoučová, & Hagl, 2014; for a review: Doering & Eisma, 2016).
Although these studies are of major importance in identifying which
interventions work best for bereaved people experiencing complica-
tions in the grieving process, there are common limitations to many of
them. First, due to practical and ethical limitations, most studies only
assess shortterm effects, which makes it difficult to assess any longer
term benefits (for notable exceptions: De Groot et al., 2007; Kersting
et al., 2013; Rosner, Bartl, Pfoh, Kotoučová, & Hagl, 2015). Second,
the majority of recent studies concern interventions that are offered
in a professional setting and not in the setting in which they are most
often delivered; in the U.K., the majority of bereavement intervention
services are provided by nonprofit sector staff and volunteers (esti-
mated at 70%90% in the U.K. by Stephen et al., 2009, and similar sit-
uations of bereavement care offered by palliative care and hospice
organizations in Australia, Japan, and the United States have been
described by Breen, Aoun, O'Connor, & Rumbold, 2014).
1.1 |The present study
A unique situation of bereavement care in Scotland and a newly devel-
oped intervention at a Scottish national organization, Cruse Bereave-
ment Care Scotland (CBCS), have presented the opportunity to
address these gaps in the research by conducting a naturalistic, longitu-
dinal study on the effectiveness of communitybased, onetoone
bereavement counselling. The CBCS intervention entails an intake
assessment process to ensure the provision of care for bereaved people
at the appropriate time (i.e., more than 6 months after loss) on an in
reaching basis. Preexisting logistical issues (described below in greater
detail) also provided for a quasirandomized, nointervention control
condition to balance the study design.
The development of the CBCS model of bereavement intervention
was theorydriven and guided by Schut and Stroebe's dual process
model of coping with bereavement (Stroebe & Schut, 1999). Following
this model, bereaved people who engage in an adaptive coping process
oscillate between lossoriented and restorationoriented behaviours,
which facilitate positive and negative reappraisals. Bereaved people
who experience complications may require support in finding pathways
to permit this oscillation in everyday life. To offer this kind of support,
the CBCS model was developed as a flexible, bereavementspecific
counselling intervention, combining elements of a number of
established therapeutic methods including cognitive behavioural ther-
apy (Boelen et al., 2007), personcentred counselling (Larson, 2013),
and the psychodynamic approach (Mikulincer & Shaver, 2008). Details
of the CBCS intervention model have been discussed in a qualitative
study by Simonsen and Cooper (2015).
The aim of the present study was to establishuniquelywhether
grief counselling offered through a communitybased organization to
helpseeking, highly distressed, and/or highrisk bereaved individuals
is effective in improving psychological and social functioning relative
to a nointervention control. There were three primary hypotheses.
First, in line with the abovementioned metaanalyses, we predicted
a greater decline in CG symptom levels in the intervention as com-
pared with the control group at posttest (1 year after baseline). Sec-
ond, following indications in the literature of a diminishment of
effect with the passage of time (Currier et al., 2008), we expected to
see a smaller difference between the slopes of symptom level change
between the intervention and the control group in the postmeasure
to followup interval (one and a half years after baseline). Third, we
also expected the difference within the study categories to be smaller
Key Practitioner Messages
Bereavement counselling for elevatedand highrisk
bereaved persons has a beneficial effect on grief
symptoms over 18 months.
Preliminary indications suggest no marked difference in
the effectiveness of bereavement counselling for
elevated versus high levels of complicated grief.
Professionally trained volunteer counselling by a non
profit organization complements professional services.
NEWSOM C. ET AL.O1513
between posttest and followup, given the potential for posttherapy
relapse. Our secondary hypotheses predicted a similar pattern of
results for symptoms associated with PTSD and symptoms of general
psychological distress.
2|METHOD
2.1 |Procedure
The present study was approved by the NHS East of Scotland Research
Ethics Committee (IRAS project ID 56758) in November 2010, with
study progress reports submitted on an annual basis until 2015. Recruit-
ment for the study took place between January and September 2011
across all mainland locations of CBCS, an independent, voluntary sector
organization specialized in delivering informational and counselling sup-
port to bereaved people at no cost to them. Each year, approximately
12,000 people contact CBCS for information and support, and about
55,000 hr of service are provided to the Scottish community.
Participants of this study were adult (age 18+) residents across
Scotland who had been bereaved for at least 6 months, had already
received basic written information in the form of leaflets on coping
with bereavement (CBCS, 2010; Kuykendall, 2005), and had contacted
CBCS to request for onetoone counselling support. Eligibility for the
study was limited to people who were actively seeking help (i.e., no
routine referrals) and were eligible to receive standard care from
CBCS. Excluded from the study on these grounds were people with
learning difficulties, cognitive difficulties, or special communication
needs (because these clients are allocated directly to volunteers with
specialized skills); people presenting with comorbid psychological
conditions such as substance abuse problems, schizophrenia, or psy-
chosis (to whom referrals for specialist care were provided); and peo-
ple presenting with strong suicidal ideation (who were supported
following a different protocol). People receiving external psychological
support were also excluded from the study. Use of antidepressant and
antianxiety medication among study participants at baseline was not
an exclusion criterion if use of medication was consistent throughout
data collection. This choice was made due to the widespread use of
antidepressants and antianxiety medication in Scotland (The Scottish
Government, 2014; cf. Shear & Shair, 2005).
Study information packs, including a written invitation to partici-
pate, were provided to eligible people either in person after a visit to
CBCS or by post following telephone contact. Participants indicated
their agreement to enrol in the study by signing and returning a study
consent form by freepost. Approximately 1,400 packs were distrib-
uted, and 349 people agreed to participate (24.9%; this rate of accep-
tance is not unusual for bereavement research, as discussed below in
Section 3.1). Of these, five people were excluded from the study
(due to external professional help received), and 344 were enrolled in
the study. Assignment to study conditions was quasirandomized.
Quasirandomization enabled us to include a nointervention control
group and a participant observation period of 18 months, while adher-
ing to ethical standards, and not denying care to helpseeking bereaved
people. Participants for whom counselling sessions could be scheduled
were assigned to the intervention condition (n=156). The control
group consisted of those who wanted counselling but were unable to
participate (in the near future; n= 188). The majority of these were
people who could not find a mutually agreeable time for counselling
sessions and/or could not arrange transport to the service location.
(Although CBCS has locations throughout Scotland, the topography
of Scotland is such that a nearby location may in reality be difficult
to reach.) There was also a small number of participants who remained
on a waiting list for intervention services due to the organization's lim-
ited capacity (at that time) to provide care in the short term.
2.2 |Sample characteristics
Demographic details and lossrelated characteristics of the study sam-
ple are presented in Table 1 (for group comparisons, see results).
Seventynine percent of participants were females.
1
The mean age of
participants was 49.3 years (SD = 14.20), with a range from 20 to
85 years. The majority of the sample had lost a partner (38%) or parent
(37%) within the previous 2 years (80%) and reported that the death
had been unexpected (63%).
2.3 |Intervention
The CBCS intervention model was developed specifically for the provi-
sion of onetoone counselling support to adults who are experiencing
difficulties in coping with bereavement. Informed by the dual process
model of coping with bereavement (Stroebe & Schut, 1999), the inter-
vention aims in part to normalize the participant's grief reaction when
needed and to create a safe holding environment for the participant to
express and confront emotions relating to the bereavement. This plu-
ralistic model of bereavement intervention incorporates components
of three therapeutic traditions. From the personcentred approach,
these include unconditional positive regard, empathy, and congruence;
from CBT, they include guided exposure exercises adapted to meet
individual needs; and from the psychodynamic tradition, they include
an awareness of attachment patterns that may inform grief reactions.
(For more detail, as well as a client's perspective, see Simonsen &
Cooper, 2015.)
At baseline, an intake assessment was conducted by a purpose
trained volunteer using the IBACS, a validated assessment instrument
for bereavementrelated grief and risk factors (Newsom, Schut,
Stroebe, Birrell, & Wilson, 2016; Newsom, Schut, Stroebe, Wilson, &
Birrell, 2016). The minimum IBACS score was 0; the maximum was
55. Clinical indications for the IBACS currently maintained a minimum
threshold of 19 points for bereavement intervention. Bereaved people
who received fewer than 19 points were considered to be coping
effectively on their own, and intervention is not indicated. Likewise,
people who received more than 54 points were to be considered in
need of urgent specialist care and would be accordingly referred to
qualified professional resources. For bereaved people who received
from 19 to 54 IBACS points, two further subcategorizations facilitated
the assignment of appropriately experienced counsellors. Participants
who received an IBACS score between 19 and 28, which corresponds
with marginal levels of CG, were allocated to the skilled listener cate-
gory. Placing the current intervention design in the context of existing
categories (following the indications from Schut et al., 2001) described
1
For further comments on this characteristic, please see below in Section 4.
O1514 NEWSOM C. ET AL.
TABLE 1 Baseline personal characteristics of control and Cruse Bereavement Care Scotland (CBCS) participants
Control CBCS
(N= 188) (N= 156)
Demographic characteristics
Age in years (mean [SD]) 48.5 (14.17) 50.1 (14.48)
n(valid %) n(valid %)
Gender 188 156
Female 146 (77.66%) 125 (80.13%)
Income 150 137
Below median 62 (41.33%) 40 (29.20%)
Median 34 (22.67%) 46 (33.58%)
Above median 54 (36.00%) 51 (37.23%)
Living with a partner 181 153
Yes 52 (28.73%) 51 (33.33%)
No 129 (71.27%) 102 (66.67%)
Participant has children** 185 153
No 53 (28.65%) 63 (41.18%)
Yes 132 (71.35%) 90 (58.82%)
Use of medication at baseline* 183 156
No 91 (49.73%) 91 (58.33%)
Yes, antianxiety/antidepressants 84 (45.90%) 58 (37.18%)
Yes, other (incl. sleeping pills) 8 (4.37%) 7 (4.49%)
Lossrelated characteristics
Time since the death* 180 154
6 months 38 (21.11%) 37 (24.03%)
Between 612 months ago 64 (35.56%) 58 (37.66%)
12 years ago 44 (24.44%) 35 (22.73%)
25 years 23 (12.78%) 18 (11.69%)
5+ years ago 11 (6.11%) 6 (3.90%)
Relationship to the deceased** 186 155
Partner 75 (40.32%) 54 (34.84%)
Parent 75 (40.32%) 53 (34.19%)
Sibling 11 (5.91%) 17 (10.97%)
Child 18 (9.68%) 19 (12.26%)
Other friend/relative 7 (3.76%) 12 (7.74%)
Quality of the relationship 184 155
Very good/good 169 (91.85%) 144 (92.90%)
Reasonable 7 (3.80%) 7 (4.52%)
Not good/bad 8 (4.35%) 3 (1.94%)
No relations 0 1 (0.65%)
Expectedness of the death 182 154
Expected 35 (19.23%) 33 (21.43%)
Neither expected nor unexpected 30 (16.48%) 22 (14.29%)
Unexpected 117 (64.29%) 99 (64.29%)
Other resources contacted (prior to study)** 182 153
No 116 (63.74%) 123 (80.39%)
Yes (psychiatrist) 9 (4.95%) 5 (3.27%)
Yes (psychologist, counsellor, therapist) 38 (20.88%) 18 (11.76%)
Yes (support group, other social organization) 14 (7.69%) 7 (4.58%)
Outcome measures at T1 (unadjusted means)
MSDMSD
Impact of Event Scale 44.96 19.68 43.04 18.19
Inventory of Complicated GriefRevised 68.42 25.86 64.78 23.68
Symptom Checklist 90R 151.72 80.10 132.33 71.11
*p< .05.
**p< .001.
NEWSOM C. ET AL.O1515
in the introduction, counselling for this category would be considered a
secondary intervention, because it was a preventative intervention for
people with elevated symptoms of grief who were at risk of developing
CG. Participants who reached an IBACS score of 29 to 54, indicating
high CG levels, were allocated to the advanced skills/counsellor cate-
gory. This score range roughly corresponds with CG caseness, and
counselling in this category would be considered a tertiary intervention
in Schut et al.'s (2001) framework.
Counsellors working with participants in the skilled listener cate-
gory and those working with participants in the advanced skills listener
category offer support based on the same intervention model; only
their hours of experience are different. All counsellors have completed
(at a minimum) a yearlong diplomalevel course in counselling (certi-
fied by the Scottish counselling authority, COSCA) as well as a
COSCAcertified griefspecific training module (details can be
requested through the national office of CBCS). Counsellors are pro-
moted from the skilled listener to the advanced skills counsellor cate-
gory after completing an additional 60 hr of supervised, clientfacing
work, along with requisite continuing professional development hours.
Sixtysix volunteer counsellors delivered care in this study. Participants
worked with the same counsellor at each session. Counselling sessions
were held at CBCS locations across Scotland in quiet rooms with com-
fortable, nonclinical furnishings. Participants attended counselling
sessions on a weekly basis, scheduled at their convenience in the day
or evening. Sessions lasted 50 min. Standard CBCS procedure is to
offer clients six sessions, though a participant and counsellor may
mutually agree to adjust the number of sessions as needed. An average
of six sessions of counselling was offered (M=6.32, SD = 3.09).
2.4 |Data collection procedure
Data for the present study were collected at three time points:
baseline, T1; posttreatment, T2 (T1 + 12 months); and followup, T3
(T1 + 18 months). Time intervals were standardized to be uniform
across conditions. Duration of the period from intake through
completion of intervention varied from participant to participant, with
an average length of 9 months. Because the intake plus intervention
period was universally completed by 12 months, we selected
12 months as a standard interval between T1 and T2.
2.5 |Measures
Five instruments were used in the present investigation: a measure of
demographic and lossrelated characteristics (administered at T1); an
intake assessment instrument measuring bereavementrelated distress
and risk of developing complications (administered at T1); a primary
measure for CG symptoms; and secondary measures to assess PTSD
symptoms and general psychological health symptoms (administered
at T1, T2, and T3).
2.5.1 |Bereavementrelated distress and risk of complica-
tion (intake assessment)
IBACS (Newsom, Schut, Stroebe, Wilson, et al., 2016) was adminis-
tered to measure baseline levels of bereavementrelated grief symp-
toms and the risk of developing complications while grieving due to
the presence of known risk factors. Risk factors were assessed through
a semistructured interview; symptoms of bereavementrelated distress
were measured with a structured question set. A validation exercise
for the IBACS demonstrated convergent validity with other instru-
ments including the Inventory of Complicated GriefRevised (ICGR;
Prigerson & Jacobs, 2001; r= .82, p< .01) and cutoff score conver-
gence with CG casenesscalculations using the ICGR (Newsom,
Schut, Stroebe, Birrell, et al., 2016).
2.5.2 |Demographic and lossrelated characteristics
A selfconstructed questionnaire was used to assess demographic
characteristics (gender, age, lives with a partner (yes/no), has children
(yes/no), and income) and lossrelated characteristics (time since loss;
relationship with the deceased; expectedness of the death; quality of
the relationship with the deceased; and medication use).
2.5.3 |Complicated grief
Symptoms of CG were assessed with the 30item ICGR (Prigerson &
Jacobs, 2001). Strong internal consistency (Cronbach's α= .94) has
been reported for the ICGR (Prigerson & Jacobs, 2001). Convergent
validity for the ICG (Dutch version) was demonstrated through a high
correlation (r= .71, p< .05) with The Texas Revised Inventory of Grief
(Boelen, Van den Bout, De Keijser, & Hoijtink, 2003). Convergence
with the outcome of the structured clinical interview protocol, the
Traumatic Grief Evaluation of Response to Loss (Prigerson & Jacobs,
2001) confirmed construct validity. In the present investigation, base-
line reliability was excellent, α= .95, and was minimally higher at the
two subsequent time points (α= .96).
2.5.4 |PTSDrelated symptoms
Symptoms of avoidance, hyperarousal, and intrusion were assessed
using the Impact of Event ScaleRevised (IESR). The IESRisa
22item questionnaire, addressing the abovelisted symptoms, which
conform to DSMIV criteria for PTSD. Strong testretest reliability
(r= .89 to .94) has been reported for the IESR (Weiss & Marmar,
1996), and convergent validity with the PTSD checklist has been dem-
onstrated with a high correlation of r= .84 (Creamer, Bell, & Failla,
2003). In the present study, reliability was excellent at baseline,
α= .92, and continued to be at T2, α= .94, and at T3, α= .95.
2.5.5 |General psychological symptoms
The Symptom Checklist 90 Revised (SCL90R; Derogatis & Cleary,
1977) is a 90item questionnaire addressing general psychological
health symptoms that can be divided into nine domains: anxiety,
depression, hostility, interpersonal sensitivity, obsessive compulsive
symptoms, paranoid ideation, phobic anxiety, psychoticism, and soma-
tization. Internal consistency has been shown to range from α= .74 to
.97 (Prinz et al., 2013). Each domain has demonstrated construct valid-
ity (Derogatis & Cleary, 1977), and validity as a unidimensional scale
has been established for the depression, phobic anxiety, and interper-
sonal sensitivity subscales (Bech, Bille, Møller, Hellström, &
Østergaard, 2014). Average positive symptom scores can be used to
calculate the Global Severity Index, a general symptom severity rating,
which was used in the present study (Derogatis & Cleary, 1977;
O1516 NEWSOM C. ET AL.
Derogatis & Unger, 2010). Baseline reliability was excellent in the pres-
ent investigation, α= .98, and maintained at both T2 and T3.
2.6 |Statistical analyses
Three main operational hypotheses were formulated to investigate the
primary research question. We expected to find (a) the slope (i.e.,
decline) of mean grief symptoms in the intervention condition would
be greater than in the control condition between T1 and T2; (b) a dif-
ference between the slopes of change of the intervention and the con-
trol conditions between T2 and T3; (c) a greater slope of change
between T1 and T2 than between T2 and T3 in both study categories
(this hypothesis was tested separately for each group). Next, the same
hypotheses were to be tested for secondary outcomes (i.e., PTSD and
general psychological health symptoms).
A random effects model for fixed occasions was developed to ana-
lyse the data (Snijders & Bosker, 2012). An average score was esti-
mated for the outcome variable at each time point for the
intervention and control conditions. Where baseline differences in
demographic or lossrelated variables between conditions were
detected, these variables were added as covariates. Assumptions of
linearity, multicollinearity, homoscedasticity, and normality of residuals
were tested prior to analysis. To account for the longitudinal nature of
the data, a multilevel regression was conducted using MLwiN
(Rasbash, Steele, Browne, & Goldstein, 2015), with repeated measures
nested within subjects, and a random effect of time included to
account for withinsubject correlations. Estimation of model parame-
ters and standard errors was conducted with full information maximum
likelihood with robust standard errors.
Change in outcome variables across time was measured by calcu-
lating the slope of change of adjusted mean scores for both study
conditions. For each condition, the adjusted mean at T2 was
subtracted from that of T1, and the adjusted mean at T3 from that
at T2. Positive values indicate a decline of griefrelated symptom
scores between time points. The slopes were compared across study
conditions to answer research questions 1 and 2 and across time
within both study conditions separately to answer research question
3. Twosided tests were conducted with a significance level of
α= 0.05.
Following Wang et al. (2015), a stepwise serial gatekeeping proce-
dure was selected to address multiple hypotheses testing in the output
of the model and reduce the risk of Type 1 (false positive) errors. This
procedure affords the flexibility of testing families of hypotheses in
order of their relevance to the main research question, reserving
power for the most critical research questions.
The first step of the process was to establish a hierarchy in the
families of hypotheses. Because we planned to test our three opera-
tional hypotheses on three different sets of outcome measures (i.e.,
ICGR, IESR, and SCL90R), we structured the analysis by placing
the three operational hypotheses into three families, each defined
according to the relevance of the outcome measures to the objectives
of the bereavement intervention. Because symptoms of CG (ICGR)
are bereavementspecific complaints, this was the primary outcome
measure, and its hypotheses were the first family in the hierarchy.
PTSD symptomatology (IESR) was a secondary outcome measure
and the second family of hypotheses. This was due to the close asso-
ciation between the instruments' subscale measures (avoidance, intru-
sion, and hyperarousal) with grief symptoms (e.g., Boelen & Eisma,
2015; Boelen, Huntjens, van Deursen, & van den Hout, 2010). The
family of hypotheses concerning general symptoms (SCL90R) was
placed third, because the impact of bereavement intervention on these
nongriefspecific measures was less direct.
Significance testing was then conducted, with the four null
hypotheses for the primary outcome variable, grief, tested at
α= 0.05. Only if all of these were rejected would the null hypotheses
for the secondary outcomes be tested and so forth down the hierarchy
of families. In other words, if any null hypotheses in the family were
not rejected, results of this first family of analysis would be retained,
and no testing of subsequent families would be conducted.
Normality of residuals at both the repeated measures level and
subject level was checked by means of QuantileQuintile (QQ) plots.
Homoscedasticity of the residuals at both levels was checked by
means of scatter plots in which the residuals were plotted as a function
of predicted scores.
2.7 |Clinical significance
To evaluate the clinical significance of results within the framework of
a naturalistic study where absolute recovery is not expected but a
demonstrated reduction in symptoms is meaningful (cf. Wise, 2004),
a categorical CG caseness variable was calculated by following the
indications by Prigerson and Jacobs (2001) using a specific selection
of items from the ICG (cf. Boelen et al., 2007). The variable was used
to indicate whether mean CG symptoms exceeded a minimum clinical
threshold value. To compare CG caseness across conditions, a
crosstabs analysis was conducted in a subset of the data that only
included participants who had provided complete data sets at all three
measurement points.
Lastly, based on the ambiguous indications in the literature
concerning the effectiveness and clinical relevance of secondary inter-
ventions, the opportunity was taken to conduct an additional explor-
atory analysis to determine whether there were differences in
symptom changes between participants (within the intervention condi-
tion) who received intervention on a secondary or preventative basis
and those who received it on a tertiary or indicated basis. Using a
mixed, repeated measures analysis of variance and omitting incom-
plete cases, we compared the magnitude of symptom change among
participants who received intervention on a secondary basis and those
who received it on a tertiary basis across time, specifically the intervals
betweenT1 and T2; T2 and T3; and T1 and T3. Although this test could
provide only preliminary information, we believed this exploratory step
would provide useful indications for future research.
3|RESULTS
3.1 |Participant flow
Figure 1 provides details of study attrition by condition across time
points. The response rate for all three time points (cumulatively) was
41%. Though the attrition rate may appear high, it is not unusual for
longitudinal bereavement research involving postal questionnaires
NEWSOM C. ET AL.O1517
(Aoun et al., 2015). As Figure 1 illustrates, the majority of study attri-
tion was through nonresponse. In order to respect participants' deci-
sions to withdraw and to protect their confidentiality, after one
reminder letter, no further steps were taken to track nonresponsive
participants. Voluntary withdrawal from the study (n=5) was indicated
either by telephone or through written notification by post. Study
withdrawal was attributed to no longer wishing to reflect on their
bereavement experiences. Of these, three participants attributed their
decisions to feeling better, and two stated that reflecting on the
bereavement evoked unwanted sad feelings. Nine participants were
excluded because they received outside professional support for
bereavement.
3.2 |Attrition
Completers of all measurements and noncompleters did not signifi-
cantly differ on gender, use of medication, expectedness of the death,
contact with other support services prior to CBCS, or levels of CG,
posttraumatic stress, and general psychological functioning. However,
a mediumsized difference (d= .32) was detected for age (study com-
pleters were older at baseline [M= 52.23, SD = 13.14] than
noncompleters [M= 47.86, SD = 13.80; t(336) = 2.91, p= .004]). Small
differences were also detected for kinship (those who lost a partner
were less likely to drop out; those who lost a parent were more likely
to drop out, χ
2
(4) = 15.14, p= .004, r= .21) and time since
bereavement (more participants who had been bereaved just 6 months
prior to baseline were more likely to drop out; participants who were
bereaved 1 to 2 years prior to baseline were less likely to drop out,
χ
2
(4) = 16.78, p= .002, r= .22).
Completers also had a lower mean IESR scores at baseline
(M= 41.62, SD = 18.49) than noncompleters, M= 45.81, SD = 19.23;
t(338) = 2.10, p= .045, though again this difference was small, d= .22.
3.3 |Baseline characteristics
Table 1 shows baseline measures of demographic and lossrelated
characteristics, and outcome measure means of the study sample by
condition. Chisquare tests revealed no significant differences
between participants in the intervention and control conditions with
respect to gender, household income, expectedness of the death, the
reported quality of the relationship to the deceased person, or whether
the participant was living with a partner.The ttests indicated that age
and outcome measure scores were also not significantly different
across conditions.
Nevertheless, some differences between groups existed at base-
line. Control group participants were more likely to have lost a partner
or parent, χ
2
(5) = 22.39, p< .001; contacted other support resources
prior to the study, χ
2
(6) = 31.68, p< .001; and used antianxiety or
antidepression medication at baseline, χ
2
(2) = 8.08, p= .018. There
was also a slight difference in the time since the death, detected in
FIGURE 1 Flow of participants
O1518 NEWSOM C. ET AL.
an independent sample ttest treating time since loss as an ordinal var-
iable, t(1000) = 2.02, p=.044. These four variables (kinship, resources
contacted, medication use, and time since the death) were used as
covariates in the main analyses.
3.4 |Statistical tests
The overall focus of our analysis was the comparison of two slopes
across conditions (intervention vs. control) for our three outcome mea-
sures, CG, posttraumatic stress, and general psychological health. We
compared two slopes: slope 1 (between T1 and T2) and slope 2
(between T2 and T3). As noted, we expected that there would be dif-
ferences between the slopes across conditions (Hypotheses 1 and 2).
We also expected that in both study conditions, the first slope would
differ from the second (Hypothesis 3).
3.5 |Model assumptions for a linear multilevel model
The outcomes in the present analysis were sum scores of subscales
with a large enough number of values for the variables to be treated
as continuous variables. Scatterplots were generated to examine the
linearity of the relationship between sum score outcomes and the con-
tinuous variable covariate, time since death, which was an ordinal var-
iable with eight categories. Scatterplots indicated a linear relationship
between outcome and time since the death. The variance inflation fac-
tor (VIF) was calculated using dummy variables for each nominal vari-
able, and the results (VIF < 10) ruled out multicollinearity. An
examination of scatterplots of residuals at both levels revealed no vio-
lation of the assumption of homoscedasticity, and PP plots showed no
violation of normal distribution of residuals. Histograms indicated a
normal distribution of variables at T1 for the ICG and the IESR sum
score. SCL90 sum scores were not normally distributed; however, this
was not unexpected due to the inclusion criteria of the study, which
limited participation to those people who presented with elevated
levels of grief symptoms. Although histogram plotting revealed that
the sum scores did not all follow a normal distribution, this did not
present a problem because the multilevel model assumes a normal dis-
tribution of residuals.
3.6 |Complicated grief symptoms (ICG)
Figure 2 illustrates the covariateadjusted means of the ICG scores
across conditions over the three time points. The first family of tests
contained the three groupings of hypotheses for CG symptoms mea-
sured by the ICG. Results for Hypothesis 1 indicated that symptom
levels of CG declined over the 12 months between T1 and T2 in both
study conditions with a similar slope of change, χ
2
(1) = .113, p= .727.
In the intervention condition, the mean of grief symptom levels
decreased from T1 (M= 70.93) to T2 (M= 60.68), and in the control
condition, the mean decreased from T1 (M= 72.87) to T2
(M= 61.73). The difference in the decrease in grief levels between
the two study conditions at these time points was not statistically sig-
nificant. This indicates a rejection of Hypothesis 1, as the intervention
had no apparent impact at the posttest shortly after its completion.
For Hypothesis 2, it was postulated that the slope of symptoms
would differ between the intervention group and the control category
between T2 and T3. Results confirmed Hypothesis 2 and revealed that
the change in mean CG scores over the 6 months between T2 and T3
was greater for the intervention condition, with a decline from T2
(M= 60.68) to T3 (M=53.64), compared to the control group, where
mean symptom scores increased from T2 (M= 61.73) to T3
(M=62.00), χ
2
(1) = 6.01, p= .014, d=.33. Complicated grief symptoms
decreased relatively more in the intervention group between
postmeasure and followupafter bereavement, counselling was com-
pleted for some timethan between baseline and postmeasure, when
participants had just completed counselling.
Tests with the ICG also confirmed Hypothesis 3, which suggested
that the slope of change in symptom levels would be greater within the
intervention category and the control category between T1 and T2
than between T2 and T3. Results indicated that, for both groups, the
slope of withingroup change of mean symptom levels was greater
between T1 and T2 than between T2 and T3, χ
2
(1) = 5.48, p= .019.
Within the intervention group, the mean decreased 7.03 points
between T2 and T3 compared to a decrease between T1 and T2 of
10.3 points. The effect size of this difference was small (d=.27).
Within the control group, the mean decrease between T2 and T3
was negligible (0.27 points). The mean decrease between T1 and T2,
in contrast, was 11.0 points, with a smalltomedium effect size
(d=.43).
Although pvalues for the results of Hypotheses 2 and 3 for CG
were sufficient to reject the null hypotheses, the pvalue for Hypothe-
sis 1 was not. Following the serial gatekeeping procedure, to reduce
the possibility of a false positive, results for this family were retained,
and no further testing of families in the dataset was conducted. All null
hypotheses for the second group of hypotheses, and indeed all subse-
quent groups, were therefore not tested.
3.7 |Change criteria
Figure 3 illustrates changes in CG caseness per study condition across
the three time points. As an indicator of clinically meaningful change,
CG caseness was calculated in both study conditions across time
points and compared in a crosstabs analysis. Only cases with complete
data across all three measurement points were included in the analysis;
therefore, the available sample was smaller (n=116; 62 intervention,
FIGURE 2 Inventory of Complicated Grief mean scores (adjusted for
kinship to the deceased person, resources contacted, medication use,
and time since the death) across time points
NEWSOM C. ET AL.O1519
54 control) than the sample for the multilevel model. At baseline (T1),
positive CG caseness was detected in 61% (n=38) of the intervention
conditions (M=.61, SD = .49) and 57% (n= 31) of the control condi-
tions (M=.57, SD = .50), with no notable difference between the
groups; t(114) = .422, p=.674. At followup (T3), CG caseness was
reduced to 31% (n= 19) of the intervention condition (M=.31, SD = .46)
compared to 48% (n=26) of the control group (M=.48, SD = .50). The
difference between the groups at T3 indicated only marginal statistical
significance, t(114) = 1.94, p=.054.
Using the intervention category participants from this same subset
of the sample, a mixed repeated measures analysis of variance was
conducted to explore the differences in the change in grief symptom
levels for secondary and tertiary intervention category participants
over time. The sample was again restricted to intervention category
participants who had complete data sets at all three time points (the
inclusion of itemlevel T2 data in this analysis made the sample slightly
smaller, n=56; secondary n= 31; tertiary n= 25). The difference in
symptom levels on the ICG was calculated as a continuous variable
for T1T2, T2T3, and T1T3 intervals. No interaction was detected
between the intervention basis (secondary or tertiary) and timeWilks'
lambda = .96, F(2, 53) = 1.04, p= . 359, partial eta squared = .038
indicated a small to moderate effect size. A substantial main effect
for time was detectedWilks' lambda = .59, F(2, 53) = 18.61,
p= <.001, partial eta squared = .413denoting a large effect size
and indicating that both secondary and tertiary intervention categories
experienced a decrease in symptom levels across time. The main effect
comparing secondary and tertiary interventions indicated no detect-
able differences, F(1, 54) = .517, p= .475, partial eta squared = .009.
The results suggest that there may be no difference in the change in
CG symptom levels when bereavement intervention is offered on a
secondary or a tertiary basis.
4|DISCUSSION
The objective of this controlled intervention study was to test the
effectiveness of a widely available approach to bereavement counsel-
ling in reducing symptoms of griefrelated distress among help
seeking, bereaved adults. Like most bereavement intervention, as
noted in our introduction, the intervention was offered through the
voluntary (nonprofit) sector. Results of the investigation indicated
that people who received bereavement counselling experienced a
greater decrease in grief symptoms over time than a bereaved cohort
that did not receive counselling. Time itself was found to have a strong
effect on levels of grief in both conditions between baseline and 12
month followup. In the intervention group, grief symptom levels con-
tinued to decline; however, between the 12month postmeasure and
the 18month followupafter counselling had been completedthe
control group's mean symptom levels remained unchanged. It there-
fore appears that distressed and atrisk bereaved people who receive
counselling experience a reduction in CG symptoms in addition to
the effect of time after the counselling is completed. Due to correc-
tions for multiple hypothesis testing, we were unable to produce
results for the other outcome variables included in the analysis.
Though it appeared that no, or at best minimal, effects would be
detected for bereavement counselling on symptoms of PTSD or gen-
eral psychological health, further research is needed to make a valid
assessment.
When considering the clinical implications of these results, two
observations are notable. First, more clinical improvement was
observed in CG symptom levels (as indicated by an analysis of a grief
caseness variable) among participants who had received counselling
intervention; however, this effect was only marginally significant. Sec-
ond, although the results of the investigation indicated that counselling
intervention had a positive effect, this effect was markedly protracted.
A primary factor contributing to this result was the reduction in symp-
tom levels in the control condition that approximately matched that of
the intervention condition between baseline and 12month followup.
Were it not for the second factor contributing to the study's results
the substantial drop in CG symptoms after counselling in the interven-
tion group relative to the control groupwe might have considered the
intervention to have had no effect at all.
One explanation for this delayed effect may be the experience of
grief counselling itself. Because counselling sessions require partici-
pants to confront difficult aspects of bereavement, it is possible that
intervention participants experienced slightly elevated grief symptom
levels during the counselling period and even the short term thereafter,
leading up to postmeasure. Then, in the months following the post
test, intervention participants' grief symptoms once again declined,
and ultimately due to counselling, this decline was steeper than in
the control group. In other words, the effort of working through,
which is integral to counselling, would initially be reflected in elevated
grief scores, then by a decline once these disturbing aspects were dealt
with.
This specific effect has not been demonstrated in previous psy-
chotherapy research for CG (e.g., Boelen et al., 2007; Rosner et al.,
2014), so it is important to consider additional reasons for the delayed
effect on CG. Differences in study design between the present and
previous investigations could offer a partial explanation. Most notably,
although the length of intervention in the present study varied, there
was a full year between baseline and posttest, which is longer than
study intervals in nearly all previous intervention trials on CG
employing a waitlist control (Doering & Eisma, 2016). It is therefore
FIGURE 3 Change in complicated grief (CG) caseness over time,
indicating abovethreshold level symptoms of CG measured using the
Inventory of Complicated Grief
O1520 NEWSOM C. ET AL.
also possible that the healing effect of time may be more pronounced
in our study compared to other trials.
The fact that greater symptom change was observed in the inter-
vention group at 18month followup is important for a number of rea-
sons. First, for bereaved people who receive counselling, and for
counsellors who provide it, the results provide a positive indication
that counselling helps more than the passage of time alone. It may be
that people initially attribute feeling better to counselling, whereas
time alone might have reduced their suffering from grief as much;
but in the long term, counselling has been shown to have a more ben-
eficial effect and will reduce griefrelated symptoms further. For
bereavement researchers, the results demonstrate the importance of
a longitudinal study design, including a lengthy period between mea-
surements. Data collection at additional time points both during and
after counselling could also provide more insight into when changes
in grief levels occur over time.
The effectiveness of communitybased counselling also suggests it
to be a potentially costeffective alternative to professional grief
counselling. Though the effect is modest, it must be noted that com-
munitybased counselling initiatives currently have a larger reach than
professional grief counselling interventions. Future research should
include costeffectiveness analyses of different intervention alterna-
tives for distressed bereaved persons.
4.1 |Limitations
The present study's naturalistic, longitudinal design was selected for
scientific as well as ethical reasons, but it also introduced limitations
that should be considered when interpreting the results. First, our
study sample was divided into conditions through a quasirandomized,
and not a strictly random, procedure, which would have been prefera-
ble from a statistical perspective. Although previous metaanalytic
studies of psychotherapeutic interventions for bereavement showed
no statistically significant differences between outcomes of studies
with a randomized or a nonrandomized design (Currier et al., 2008),
and despite our every effort to identify and control for any differences
between our participant groups, it is impossible to be certain that there
were no underlying differences that escaped measurement. A second
limitation concerns the generalizability of results. Our sample, which
was representative of the counselling organization's usual client base,
was predominantly female, as is commonly the case in bereavement
research and indeed in grief counselling at large (Stroebe, 2001). In
addition, a majority of our sample was bereaved of a parent or partner.
Though research has indicated that both the relationship to the
deceased person and being a woman increased the likelihood of devel-
oping a CG reaction (Burke & Neimeyer, 2013), men have also been
shown to be at greater risk of experiencing difficulties specifically after
a spousal bereavement (Stroebe, 1998). Further investigation of the
effectiveness of bereavement counselling for men and with greater dif-
ferentiation among bereaved people's kinship ties to the deceased
would be warranted. Lastly, excluding participants who take anti
depressant or antianxiety medication would have been preferable;
however, this was not feasible, given the indications that one in seven
Scottish residents takes antidepressants (cf. The Scottish Govern-
ment, 2014; BBC News, 2012). No differences were found in the use
of these types of medications across study groups, however, and
though it is difficult to assess whether prescription drugs had an
impact on participants' CG symptoms, indications from a recent
largescale trial by Shear et al. (2016) demonstrating a lack of efficacy
for antidepressant medication alone on CG symptoms make it unlikely
that medication use would have influenced outcomes. Lastly, though
attrition analysis indicated some, predominantly small differences
between completers and noncompleters, which were in line with par-
ticipation patterns in bereavement research (Stroebe & Stroebe,
1990), it is worth noting that completers had lower PTSD symptoms
at baseline. It is possible that people experiencing elevated PTSD
related symptoms were underrepresented at posttreatment assess-
ment, though the effect size for this difference was small.
4.2 |Conclusion
The present study demonstrated the delayed, and possibly prolonged
effect (at least for a period beyond a year) of a communitybased, plu-
ralistic model of bereavement counselling for people at risk of develop-
ing, or already experiencing, CG. The investigation incorporated a
number of recommendations from scientific research: waiting a num-
ber of months post bereavement before providing counselling; offering
counselling on an inreaching basis; incorporating an intake assessment
process to screen for CG symptoms and risk factors; and offering a tai-
lored model of counselling. The effectiveness of this approach pro-
vides encouragement for supporting communitybased initiatives to
promote psychological wellbeing. Similar to an estimated 80%90%
of all bereavement support services in the U.K. (Stephen et al., 2009),
the counselling service in this investigation was delivered by trained,
professionalgrade volunteers at a nonprofit organization, where ser-
vices are available to clients at no cost to themselves. Taken in a
broader perspective, considering the longterm effects of elevated
grief symptoms (e.g., increased days in hospital) and costs of acute care
(cf. Stephen et al., 2015), there are good reasons to conclude that com-
munitybased bereavement counselling may allow health boards to
increase the availability of support, reduce costs, and save rather than
spend.
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NEWSOM C. ET AL.O1523
... The reasons for this can be manifold. Previous studies have noted that time is a strong factor, especially with regard to grieving (Newsom et al., 2017). It can be assumed that many people process their own grief in a healthy way, even without therapeutic support. ...
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... However, Johannsen et al.'s (2019) meta-analysis reported moderate to high levels of sample heterogeneity, whereas this review had insignificant sample heterogeneity which could be attributed to the small number of included studies for parental grief outcome. Similarly, in other child bereavement studies, psychosocial interventions such as bereavement counselling was also effective in reducing grief in the long run ( Aho et al., 2011 ;Newsom et al., 2017 ). However, individual face-to-face peer support and couple-based support group interventions were less effective in reducing parental grief ( DiMarco et al., 2001 ;Raitio et al., 2015 ). ...
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Standardized, evidence-based risk assessment is an important component in providing effective bereavement care. E-health intake assessments have been offered alongside or instead of in-person assessments, although evidence concerning the equivalence of assessment results is lacking. This article examines differences between a semi-structured intake assessment for grief intervention conducted over the telephone (N = 330) and in-person (N = 115). Differences in scores and clinical implications were evaluated. Although composite assessment scores were lower in the telephone condition, further examination revealed this occurred in the semi-structured assessment of risk of complications, not the structured grief symptom assessment. Implications for care provision are discussed.
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Multiplicity control is an important statistical issue in clinical trials where strong control of the type I error rate is required. Many multiple testing methods have been proposed and applied to address multiplicity issues in clinical trials. This paper provides an application oriented and comprehensive overview of commonly used multiple testing procedures and recent developments in statistical methodology in multiple testing in clinical trials. Commonly used multiple testing procedures are applied to test non-hierarchical hypotheses and gatekeeping procedures can be used to test hierarchically ordered hypotheses while controlling the overall type I error rate. The recently developed graphical approach has the flexibility to integrate hierarchical and non-hierarchical procedures into one framework. A graphical multiple testing procedure with "no-dead-end" provides an opportunity to fully recycle α across hypothesis families. Two hypothetical clinical trial examples are used to illustrate applications of these procedures. The advantages and disadvantages of the different procedures are briefly discussed. Copyright © 2015. Published by Elsevier Inc.