Family-Focused Grief Therapy

To examine the efficacy of family focused grief therapy on psychosocial functioning in families of patients who are terminally ill

Patients and relatives in several palliative care centers and hospices were recruited for the study. Families were randomly assigned to receive the focused grief therapy or usual care stratified based on recruitment site. Usual care consisted of standard palliative care provided by homecare programs, which involved counseling when deemed clinically appropriate. Focused grief therapy was provided by qualified family therapists who had received standardized training in the intervention. Clinical supervision of the therapists was provided throughout the trial, and fidelity to the intervention was independently evaluated from review of audiotaped sessions. Family focused grief therapy typically included four to eight sessions of 90 minutes provided across 9–18 months. It included exploration of family cohesion, communication, and handling of conflict. Families were assigned to functional classes: dysfunctional (sullen or hostile) or intermediate. Data at baseline and follow-up at 6 and 13 months postbereavement were obtained from relatives by a research assistant.

• The sample was comprised of 81 families in the intervention group (n = 232) and 28 families in the control group (n = 130).
• Mean participant age was 42 ±16 years: mean patient age was 57 years, mean spouse age was 56 years, and mean age of children was 29 years.
• The sample (all participants) was 54% female and 46% male.
• The most common cancer types were breast, lung, brain, and a mix of types.
• All patients were in palliative care or hospice programs and had a prognosis of six months.
• Median length of time from illness diagnosis to death was 25 months, and median survival from study entry was 96 days.
• Of the families, 51% were classified as intermediate functioning, 26% were designated as sullen, and 23% were categorized as hostile.
• Ninety-five percent of families had two or more children.

• Multisite
• Palliative or hospice care setting
• Eight different countries

A randomized controlled trial design was used.

• Family Environment Scale
• Family Relationships Index
• Family Assessment Device
• Brief Symptom Inventory
• Beck Depression Inventory (cognitive items)
• Social Adjustment Scale
• Bereavement Phenomenology Questionnaire

Among all participants, those receiving the study intervention had significantly greater change in mean score of the Brief Symptom Inventory (BSI) (0.12, p = 0.02). BSI showed a nonsignificant improvement at 13 months in the intervention group than in the control group. Grief phenomena diminished similarly in both groups. There was no significant difference in social adjustment in both groups. There were no other significant differences between groups. Among family members who were most distressed, differences were greater, with 0.83 improvement in the BSI (p < 0.01), Beck Depression Inventory (p < 0.01), and the Bereavement Phenomenology Questionnaire (p = 0.05). In both the intervention and control groups, the general patterns of change in outcomes measures showed overall decline in symptoms over time. Families with intermediate functioning who received the intervention had a larger reduction in conflict level at six months than intermediate families in the control group (p = 0.03). Hostile families that received the intervention deteriorated more than hostile control families over the 13 months of bereavement (p = 0.001). Intermediate families received an average of 7 sessions, sullen families received an average of 6.4 sessions, and hostile families received an average of 9.4 sessions.

Family focused grief therapy appeared to have some benefit for the most distressed family members in terms of reduction of symptoms; however, these changes were not accompanied by improvement in family functioning. This intervention may protect against pathologic grief in highly distressed individuals. Among hostile families, the intervention was counterproductive

• The study had a small sample (< 100).
• The study had many missing assessments (61 members) and a high refusal rate.
• Within the subgroup analysis of the most distressed individuals, only 20 families were represented. It is not clear how many were in the control versus the intervention groups—differences in scores reported may be greatly affected by differences in group size.
• The total number of individuals in this analysis was not provided.
• It is unclear if some of the measures were sufficiently sensitive to change in order to demonstrate response to interventions.
• Results among hostile families point to the potential for harm associated with this type of intervention.
• The study was conducted across nations that are very different (e.g., Australia, United Kingdom, Africa). It is not clear how cultural context could have affected findings, and distribution of cases did not enable relevant subgroup analysis.
• In the intervention group, 24% of families withdrew from the study, suggesting some degree of potential sample bias in the results. Functioning level of withdrawals was not reported.

Family focused interventions to mitigate grief issues may be helpful in some families for highly distressed individuals; however, among the most dysfunctional families, this type of intervention might be counterproductive. Additional research is needed to determine the appropriate role of this therapy approach in palliative care.