Psychologist, Faculty Lecturer, Department of Oncology, McGill University, Balfour Mount Palliative Care Unit, McGill University Health Center, Montreal General Hospital
New Directions in Group Counselling for Bereavement: Feasibility Results of a Meaning-Based Pilot Randomized Controlled Trial

Authors: MacKinnon, CJ1,2,3, Smith1,4, NG, Henry, M1,3, Milman, E1, Chochinov, HM5,6, Körner, A.1, Berish, M.7, Farrace, A8, Liarikos, N3, & Cohen, SR1,3

What we did: Palliative care does not end at the moment of death, and international guidelines recommend that bereavement support be offered to bereft families and friends (Hudson et al., 2012). Consistent with these guidelines, our clinical research team conducted a literature review, and subsequently developed and conducted a series of feasibility tests of a novel Meaning-Based Group Counselling (MBGC) intervention for adults following an uncomplicated bereavement trajectory. An uncomplicated grief trajectory is defined using the framework of Shear et al. (2011) including common symptoms of bereavement (e.g., yearning, deep sadness, somatic distress, etc.); overall these symptoms do not impair daily functioning. Our research was conducted in three stages: initial design using best available evidence, a feasibility test, and a pilot randomized controlled trial (RCT). Our goal was to lay the ground work for possible future large scale studies that could test the efficacy of Meaning-Based Group Counselling.

Why we did this: The clinical profile of individuals with uncomplicated bereavement includes varying levels of physical and psychological distress that do not severely impair social, occupational, and daily functioning (Shear et al., 2011), but nevertheless are distressing enough for some to seek services. Studies of the effectiveness of past psychosocial interventions targeting uncomplicated grief show a negligible effect (Currier, Neimeyer, & Berman, 2008).  However, these past studies have been critiqued for design flaws (Larson, & Hoyt, 2007), making any definitive conclusions about effectiveness premature. Our appraisal of the scholarship suggests an important step for future research  is a need for theoretically-based uncomplicated bereavement interventions for individuals actively seeking support, underpinned by sound methodology (Schut & Stroebe, 2005). We chose to focus the intervention on the meaning-making paradigm (MacKinnon et al., 2013a), a contemporary theory of bereavement adaptation that is garnering increased empirical attention (Park, 2010).

How we did it and what were our results: Our research team developed a novel Meaning-Based Group Counselling (MBGC) intervention for adults in uncomplicated bereavement (reported in MacKinnon et al., 2013b). In constructing MBGC, we carefully attended to the previous scholarly literature on bereavement. We also integrated several recent theories of bereavement and group psychotherapy, as well as aspects of recent meaning-focused psychosocial interventions developed for cancer patients.
MBGC took place weekly over 3 months and was comprised of explicit tasks and themes of meaning making. It was facilitated by two licensed mental health professionals (e.g., psychologists). See Table 1 below for a description of tasks and themes of this group counselling intervention.

Table 1: Structure of Meaning-Based Group Counseling

Session Tasks and Themes
1 Establishing norms; Exploring bereavement narratives and narrative fractures
2 Conventional bereavement group themes; Members share meaningful objects associated with the deceased
3 The Griefline Exercise; Meaningful events
4 Understandings and personal implication of the Theory of Shattered Assumption (Janoff-Bulman, 1992)
5 Personal implication of the Dual Process Model (Stroebe & Schut, 1999)
6 Understanding changes in self and the family in the aftermath of death
7 Sharing the meaning of dreaming about the deceased; Hello Again Letter (Neimeyer, 2012a) introduced
8 Sharing responses to the Hello Again Letter
9 Discovering creative, attitudinal, and spiritual souces of meaning Life Imprints (Neimeyer, 2012b) introduced
10 Sharing responses to the LIfe Imprints
11 Exploring the upcoming conclusion of the group and its meaning
12 Gains made as a result of participation and directions for the future

We first tested whether or not MBGC was feasible (e.g., could we recruit enough participants? Did enough of them finish the group?). We also tried to determine what changes might be needed to MBGC to improve usefulness by regularly consulting with our first group of 11 bereft adults participants. Lastly, we wanted to see if the results supported proceeding to a full scale RCT of MBGC.

Pilot test results suggested that the intervention was feasible (MacKinnon et al., in press): most (92%) participants completed all sessions with an average of 86% session attendance. Our first group of participants reported that the meaning-based activities were largely beneficial and assisted their coping. What emerged as particularly interesting was that MBGC acted as a learning environment with several promising outcomes: groups members learned (a) about the nature of grief; (b) how to express their grief with others; and c) how to reconstruct with others a meaningful sense of identity following loss. Our questionnaires assessed four outcomes: (a) grief; (b) anxiety; (c) depression; (d) and meaning in life. Participants generally completed the entire questionnaire battery; six individuals (23%) failed to complete instruments at either the Time 2 or 3 measures and were removed from the descriptive statistical calculations. We did not conduct any inferential statistics as the small number of participants in our study would likely lead to erroneous results. We did not identify any counter-indications to proceeding with a pilot randomized controlled trial (RCT).

In the final stage, we then paired and contrasted MBGC with a typical bereavement support group (control) offered by a local non-profit community agency. We had 26 participants enrolled for this stage, with 14 randomized to the MBGC arm (2 MBGC groups of n = 8 and 6) and 12 to the control arm (2 control groups of 6). Our goal was to see if any further changes to MBGC were necessary based on consultation with participants. We also wanted to see if participants would complete a series of questionnaires at three different time points: Time 1 was within 3 months before the intervention; Time 2 was immediately after the intervention; and Time 3 occurred 3 months after the intervention. We also evaluated the feasibility of the pilot RCT. Similar to the initial test, the pilot RCT would be declared successful if (a) qualitative data indicated that individuals did not experience an overall detrimental effect from participating; (b) there was no substantial attrition (i.e., dropouts resulted in less than 4 members in either treatment group?); and/or (c) the majority of participants completed all questionnaire batteries.

In the pilot RCT, 11 MBGC participants and 9 control participants completed all aspects of the study. We found was that no individuals in MBGC reported they were in greater distress following participation. The mean attendance in MBGC was 86%. Comparatively, those in the control arm attended on average 74% of available sessions. There was no major attrition, with 77% of participants completing all aspects of the study.  MBGC participants reported they were largely satisfied with the tasks and themes of the intervention, with only minor refinements suggested.

Descriptive statistics were calculated, including the percentage of scale range improvement between Time 1 and Time 3 (see Table 2). The largest mean difference was found in the MBGC group with a positive change of 20.25% from baseline on the Core Bereavement Items, a measure of grief, compared to 5.02% change for the control group.

Table 2: Percentage of Scale Range Improvements in the Pilot Randomized Controlled Test

  MBGC (%)
n = 11
CTRL (%)
n = 9
RGEI 6.26 7.52
CBI 20.25 5.02
HGRC-Blame and Anger 11.46 3.80
HGRC-Despair 14.71 12.66
HGRC-Detachment 11.38 -0.71
HGRC-Disorganization 11.32 -1.29
HGRC-Panic 16.57 3.87
HGRC-Personal Growth 8.33 0.00
CES-D 16.40 11.12
STAI State 12.60 6.65
STAI Trait 6.02 6.31
PIL 6.37 -0.43
GMRI 4.66 -0.75
ISLES 11.47 2.56

Abbreviations: MBGC, Meaning-Based Group Counseling Arm; CTRL, Control Arm; RGEI, Revised Grief Experiences Inventory; CBI, Core Bereavement Items; HRGC, Hogan Grief Reaction Checklist; CES-D, Center for Epidemiological Studies Depression Scale; STAI, State-Trait Anxiety Inventory; PIL, Purpose in Life Test; GMRI, Grief and Meaning Reconstruction Inventory; ISLES, Integration of Stressful Life Experiences Scale

Given the results, we concluded that there were no compelling reasons not to proceed with a fully-powered RCT of MBGC.

Some of the limitations of this study: The lack of cross-cultural research in meaning making undermines the generalizability of this theoretical paradigm to understand and support bereavement adaptation. Furthermore, the majority of group members were of dominant western cultures (i.e., heterosexual, older female, Judeo-Christian), limiting the transferability of the findings to diverse populations.

The results of this study are also limited due to data collection methods. Baseline measures were not collected immediately preceding the first session of either the MBGC or the control group, but rather upon recruitment into the study. This leaves open the possibility that natural grief adaptation may have influenced member responses prior to MBGC or control participation. We also did not control for other types of support sought and/or received prior to participation.

Certain extraneous support factors also diluted an unhindered valuation of MBGC. Specifically, some individuals partook in concurrent individual therapy, whereas others participated in a concomitant bereavement support group in the pilot testing phase.

The final limitation is the control arm of the pilot RCT. The lack of an auditing and monitoring procedure resulted in major inconsistencies between the two control groups. Specifically there were different tasks and themes in each of the two control groups, as well as incongruous group facilitation. Comparison between experimental and control arms was also hampered by differing session frequencies (weekly versus bi-weekly), as well as group duration (12 sessions versus 7 sessions) (MacKinnon et al., conditional acceptance).

What our next steps might be: In view of this study’s limitations, the results, albeit promising, should be interpreted with care and caution. The ability of MBGC to mitigate psychological distress is not yet established. At this stage of intervention development, it is appropriate to claim that MBGC is a feasible enterprise. A tentative plan is in place to conduct a fully-powered RCT of MBGC in the future. We are also currently conducting an in-depth qualitative content analysis of the session transcripts of the MBGC groups to examine how participants may collectively make meaning of their loss (MacKinnon et al., 2014).

Exchange author information: Interested clinicians and researchers can receive a copy of the MBGC intervention manual by contacting the principal investigator:

Christopher MacKinnon, Ph.D., Psychologist
Balfour Mount Palliative Care Unit, McGill University Health Center, Montreal General Hospital
christopher.mackinnon@muhc.mcgill.ca



Sources

MacKinnon, C. J., Smith, N. G., Henry, M., Milman, E., Chochinov, H. M., Körner, A., Berish, M., Farrace, A., Liarikos, N. & Cohen, S. R. (conditional acceptance). Reconstructing meaning with others in loss: Results of a bereavement group pilot randomized controlled trial. Death Studies.

MacKinnon, C.J., Smith, N.G., Henry, M., Milman, E., Berish, M., Farrace, A. Körner, A., Chochinov, H.M., & Cohen, S.R. (in press). A pilot study of meaning-based group counseling for bereavement. Omega: Journal of Death and Dying.

MacKinnon, C.J., Smith, N.G., Henry, M., Berish, M., Milman, E., Körner, A., Copeland, L., Chochinov, H.M., & Cohen, S.R. (2013). Bridging theory with emerging trends in intervention research:  Meaning-based group counseling for bereavement. Death Studies, 38 (3), 137-144.

MacKinnon, C.J., Milman, E., Smith, N.G., Henry, M., Berish, M., Copeland, L., Körner, A., Chochinov, H.M., & Cohen, S.R. (2013). Means to meaning in cancer-related bereavement: Identifying clinical implications for counseling psychologists. The Counseling Psychologist, 41(2), 216-239.

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