Grief -- The Long and the Short of It

The scientific debunking of false beliefs is as relevant today as it was when skeptics took a good look at bloodletting, alchemy, and the balancing of the four humors in the pursuit of good health.

In 1986, after all, Dr. Barry Marshall’s hypothesis that Helicobacter pylori, and not stress, might cause peptic ulcers was deemed "rubbish" – but science prevailed. In 2005, he and his colleague Robin Warren shared the Nobel Prize.

The social sciences, too, depend on science to sort out presumptions from facts.

A prime example was the DARE (Drug Abuse Resistance Education) program widely implemented in schools beginning in the early 1980s. To many, it made sense that police-led drug education and character promotion activities would help vulnerable children "Just Say No" to drugs. But when the program was subjected to well-designed trials, it was determined to be ineffective in preventing drug use and found to have, in some populations, a "boomerang effect" that escalated drug use among children who had participated.

In psychology, as in medicine, the aim is to "do no harm."

That’s why I bring to your attention to a recent article (Curr. Opin. Psychiatry 2012;25:46-51) entitled "Recent trends in the treatment of prolonged grief."

If you think back to a time in your life when you experienced acute grief, you can imagine why it has been assumed that pretty much everyone could benefit from psychotherapy to get them through this profoundly emotional and sometimes physically debilitating experience. Extreme grief can leave people reeling, disoriented, sleepless, and dysregulated. It can make a previously emotionally stable person feel detached and numb or frighteningly out of control.

Now focus your memory on the weeks and months following your acute loss. Chances are that your sleep, appetite, concentration, and mood eventually returned to normal as your exquisitely intense grief reaction subsided into a quieter, more reflective form of longing and sadness.

It turns out, as Dr. Anthony D. Mancini and his associates note in their review, that 50%-60% of people "are resilient and cope remarkably well with loss and would obviously not require professional intervention."

Another 10%-20% come to grips with their grief more slowly, but eventually come to a state of homeostasis on their own timetable.

That leaves a subset of individuals whose symptoms escalate and then persist, perhaps even for years, compromising their function and well-being. People suffering this enduring, complicated grief remain an open and jagged emotional wound. They may become depressed, hopeless, bitter, detached, or wholly focused on their loss.

They need treatment, and benefit from it, just as the small percentage of people who fail to recover after a brush with life-threatening trauma fare better if they receive exposure-based therapy for posttraumatic stress disorder.

Recent meta-analyses of grief therapy for adults conclude that overall effect sizes are vanishingly small to nonexistent when therapy is universally applied.

"By far the most benefit was evidenced in indicated interventions that specifically targeted persons with high levels of distress," the authors wrote. "Curiously, however, even indicated interventions produced effect sizes that were markedly lower than typically found for psychotherapy."

Results were similar in children, although intervening early with grieving children improved efficacy.

So what’s the worst thing that could happen if people not at risk for complicated grief are referred for unnecessary therapy?

Doing harm, of course.

The possibility of introducing iatrogenic pathology is still unresolved, but Dr. Mancini and his associates noted that "grief treatments for unproblematic grief reactions" were included in a review of "potentially harmful" psychological interventions (Perspect. Psychol. Sci. 2007;2:53-70).

Soberingly, there’s a precedent. A specific intervention aimed at preventing PTSD, critical incident stress management, has been shown to interfere with natural recovery.

In a way, it all makes evolutionary sense.

Human life through the ages has been marked by horrific trauma and agonizing sorrow, just as it has been punctuated by moments of ecstatic joy.

Coping well would clearly be a selection-worthy trait in such a context.

The authors recommend that grief therapy be "reserved for children and adults with marked and persistent distress following a loss. The longstanding assumption that grief therapy is appropriate for all grievers is no longer tenable."

When grievers screened for high levels of distress receive exposure-based therapy and the opportunity to cognitively process emotional reactions, there is benefit, several recent studies show. Not surprisingly, antidepressant therapy targeted specifically to grievers suffering symptoms of depression seems to be appropriate as well, since it seems to facilitate participation in recovery.

Specific data are not available to guide in the selection of survivors most at risk for complicated grief, but I think judgment is key.

As a physician, you have seen (and experienced) much grief.

If you detect levels of distress disproportional to the norm, or worry specifically about survivors with pre-existing mental health conditions or a history of many traumas and losses, it would seem reasonable to pay attention and to follow up. Perhaps, like the majority of people coping with loss, they will draw on social supports and inner reserves and heal just fine.

If their distress is extreme and persistent, evidence suggests it would be wise to refer them for psychosocial help in moving on.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

The scientific debunking of false beliefs is as relevant today as it was when skeptics took a good look at bloodletting, alchemy, and the balancing of the four humors in the pursuit of good health.

In 1986, after all, Dr. Barry Marshall’s hypothesis that Helicobacter pylori, and not stress, might cause peptic ulcers was deemed "rubbish" – but science prevailed. In 2005, he and his colleague Robin Warren shared the Nobel Prize.

The social sciences, too, depend on science to sort out presumptions from facts.

A prime example was the DARE (Drug Abuse Resistance Education) program widely implemented in schools beginning in the early 1980s. To many, it made sense that police-led drug education and character promotion activities would help vulnerable children "Just Say No" to drugs. But when the program was subjected to well-designed trials, it was determined to be ineffective in preventing drug use and found to have, in some populations, a "boomerang effect" that escalated drug use among children who had participated.

In psychology, as in medicine, the aim is to "do no harm."

That’s why I bring to your attention to a recent article (Curr. Opin. Psychiatry 2012;25:46-51) entitled "Recent trends in the treatment of prolonged grief."

If you think back to a time in your life when you experienced acute grief, you can imagine why it has been assumed that pretty much everyone could benefit from psychotherapy to get them through this profoundly emotional and sometimes physically debilitating experience. Extreme grief can leave people reeling, disoriented, sleepless, and dysregulated. It can make a previously emotionally stable person feel detached and numb or frighteningly out of control.

Now focus your memory on the weeks and months following your acute loss. Chances are that your sleep, appetite, concentration, and mood eventually returned to normal as your exquisitely intense grief reaction subsided into a quieter, more reflective form of longing and sadness.

It turns out, as Dr. Anthony D. Mancini and his associates note in their review, that 50%-60% of people "are resilient and cope remarkably well with loss and would obviously not require professional intervention."

Another 10%-20% come to grips with their grief more slowly, but eventually come to a state of homeostasis on their own timetable.

That leaves a subset of individuals whose symptoms escalate and then persist, perhaps even for years, compromising their function and well-being. People suffering this enduring, complicated grief remain an open and jagged emotional wound. They may become depressed, hopeless, bitter, detached, or wholly focused on their loss.

They need treatment, and benefit from it, just as the small percentage of people who fail to recover after a brush with life-threatening trauma fare better if they receive exposure-based therapy for posttraumatic stress disorder.

Recent meta-analyses of grief therapy for adults conclude that overall effect sizes are vanishingly small to nonexistent when therapy is universally applied.

"By far the most benefit was evidenced in indicated interventions that specifically targeted persons with high levels of distress," the authors wrote. "Curiously, however, even indicated interventions produced effect sizes that were markedly lower than typically found for psychotherapy."

Results were similar in children, although intervening early with grieving children improved efficacy.

So what’s the worst thing that could happen if people not at risk for complicated grief are referred for unnecessary therapy?

Doing harm, of course.

The possibility of introducing iatrogenic pathology is still unresolved, but Dr. Mancini and his associates noted that "grief treatments for unproblematic grief reactions" were included in a review of "potentially harmful" psychological interventions (Perspect. Psychol. Sci. 2007;2:53-70).

Soberingly, there’s a precedent. A specific intervention aimed at preventing PTSD, critical incident stress management, has been shown to interfere with natural recovery.

In a way, it all makes evolutionary sense.

Human life through the ages has been marked by horrific trauma and agonizing sorrow, just as it has been punctuated by moments of ecstatic joy.

Coping well would clearly be a selection-worthy trait in such a context.

The authors recommend that grief therapy be "reserved for children and adults with marked and persistent distress following a loss. The longstanding assumption that grief therapy is appropriate for all grievers is no longer tenable."

When grievers screened for high levels of distress receive exposure-based therapy and the opportunity to cognitively process emotional reactions, there is benefit, several recent studies show. Not surprisingly, antidepressant therapy targeted specifically to grievers suffering symptoms of depression seems to be appropriate as well, since it seems to facilitate participation in recovery.

Specific data are not available to guide in the selection of survivors most at risk for complicated grief, but I think judgment is key.

As a physician, you have seen (and experienced) much grief.

If you detect levels of distress disproportional to the norm, or worry specifically about survivors with pre-existing mental health conditions or a history of many traumas and losses, it would seem reasonable to pay attention and to follow up. Perhaps, like the majority of people coping with loss, they will draw on social supports and inner reserves and heal just fine.

If their distress is extreme and persistent, evidence suggests it would be wise to refer them for psychosocial help in moving on.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.

The scientific debunking of false beliefs is as relevant today as it was when skeptics took a good look at bloodletting, alchemy, and the balancing of the four humors in the pursuit of good health.

In 1986, after all, Dr. Barry Marshall’s hypothesis that Helicobacter pylori, and not stress, might cause peptic ulcers was deemed "rubbish" – but science prevailed. In 2005, he and his colleague Robin Warren shared the Nobel Prize.

The social sciences, too, depend on science to sort out presumptions from facts.

A prime example was the DARE (Drug Abuse Resistance Education) program widely implemented in schools beginning in the early 1980s. To many, it made sense that police-led drug education and character promotion activities would help vulnerable children "Just Say No" to drugs. But when the program was subjected to well-designed trials, it was determined to be ineffective in preventing drug use and found to have, in some populations, a "boomerang effect" that escalated drug use among children who had participated.

In psychology, as in medicine, the aim is to "do no harm."

That’s why I bring to your attention to a recent article (Curr. Opin. Psychiatry 2012;25:46-51) entitled "Recent trends in the treatment of prolonged grief."

If you think back to a time in your life when you experienced acute grief, you can imagine why it has been assumed that pretty much everyone could benefit from psychotherapy to get them through this profoundly emotional and sometimes physically debilitating experience. Extreme grief can leave people reeling, disoriented, sleepless, and dysregulated. It can make a previously emotionally stable person feel detached and numb or frighteningly out of control.

Now focus your memory on the weeks and months following your acute loss. Chances are that your sleep, appetite, concentration, and mood eventually returned to normal as your exquisitely intense grief reaction subsided into a quieter, more reflective form of longing and sadness.

It turns out, as Dr. Anthony D. Mancini and his associates note in their review, that 50%-60% of people "are resilient and cope remarkably well with loss and would obviously not require professional intervention."

Another 10%-20% come to grips with their grief more slowly, but eventually come to a state of homeostasis on their own timetable.

That leaves a subset of individuals whose symptoms escalate and then persist, perhaps even for years, compromising their function and well-being. People suffering this enduring, complicated grief remain an open and jagged emotional wound. They may become depressed, hopeless, bitter, detached, or wholly focused on their loss.

They need treatment, and benefit from it, just as the small percentage of people who fail to recover after a brush with life-threatening trauma fare better if they receive exposure-based therapy for posttraumatic stress disorder.

Recent meta-analyses of grief therapy for adults conclude that overall effect sizes are vanishingly small to nonexistent when therapy is universally applied.

"By far the most benefit was evidenced in indicated interventions that specifically targeted persons with high levels of distress," the authors wrote. "Curiously, however, even indicated interventions produced effect sizes that were markedly lower than typically found for psychotherapy."

Results were similar in children, although intervening early with grieving children improved efficacy.

So what’s the worst thing that could happen if people not at risk for complicated grief are referred for unnecessary therapy?

Doing harm, of course.

The possibility of introducing iatrogenic pathology is still unresolved, but Dr. Mancini and his associates noted that "grief treatments for unproblematic grief reactions" were included in a review of "potentially harmful" psychological interventions (Perspect. Psychol. Sci. 2007;2:53-70).

Soberingly, there’s a precedent. A specific intervention aimed at preventing PTSD, critical incident stress management, has been shown to interfere with natural recovery.

In a way, it all makes evolutionary sense.

Human life through the ages has been marked by horrific trauma and agonizing sorrow, just as it has been punctuated by moments of ecstatic joy.

Coping well would clearly be a selection-worthy trait in such a context.

The authors recommend that grief therapy be "reserved for children and adults with marked and persistent distress following a loss. The longstanding assumption that grief therapy is appropriate for all grievers is no longer tenable."

When grievers screened for high levels of distress receive exposure-based therapy and the opportunity to cognitively process emotional reactions, there is benefit, several recent studies show. Not surprisingly, antidepressant therapy targeted specifically to grievers suffering symptoms of depression seems to be appropriate as well, since it seems to facilitate participation in recovery.

Specific data are not available to guide in the selection of survivors most at risk for complicated grief, but I think judgment is key.

As a physician, you have seen (and experienced) much grief.

If you detect levels of distress disproportional to the norm, or worry specifically about survivors with pre-existing mental health conditions or a history of many traumas and losses, it would seem reasonable to pay attention and to follow up. Perhaps, like the majority of people coping with loss, they will draw on social supports and inner reserves and heal just fine.

If their distress is extreme and persistent, evidence suggests it would be wise to refer them for psychosocial help in moving on.

Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.