patient personality and time-limited group psychotherapy for complicated grief

Piper et al.Complicated Grief

Patient Personality andTime-limited Group Psychotherapyfor Complicated Grief

WILLIAM E. PIPER, PH.D.,MARY McCALLUM, PH.D.,ANTHONY S. JOYCE, PH.D., JOHN S. ROSIE, M.D.,JOHN S. OGRODNICZUK, PH.D.

ABSTRACTWe used a randomized clinical trial to investigate the interaction of two patient personal-ity characteristics (quality of object relations [QOR] and psychological mindedness [PM])with two forms of time-limited, short-term group therapy (interpretive and supportive) for139 psychiatric outpatients with complicated grief. Findings differed depending on theoutcome variable (e.g., grief symptoms, general symptoms) and the statistical criterion(e.g., statistical significance, clinical significance, magnitude of effect). Patients in boththerapies improved. For grief symptoms, a significant interaction effect was found forQOR. High-QOR patients improved more in interpretive therapy and low-QOR patientsimproved more in supportive therapy. A main effect was found for PM. High-PM patientsimproved more in both therapies. For general symptoms, clinical significance favored in-terpretive therapy over supportive therapy. Clinical implications concerning patient-treat-ment matching are discussed.

Losing a significant person through death is a common experience.Successfully adapting to such loss is not. There is no standard definitionor diagnosis for pathological reactions to loss (Marwit, 1996). Neverthe-

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INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 51(4) 2001

Dr. Piper is Professor and Dr. Ogrodniczuk is Clinical Assistant Professor, Departmentof Psychiatry, University of British Columbia. Dr. McCallum is Associate Clinical Professor,Dr. Joyce is Associate Professor, and Dr. Rosie is Clinical Professor, Department of Psychia-try, University of Alberta.

This research project was supported by Grant MT-13481 from the Medical ResearchCouncil of Canada. We thank John G. O’Kelly and David Shih, who served as assessors; J.Fyfe Bahrey, Andrea Duncan, and Scott C. Duncan, who served as therapists; and Maarit H.Cristall and Hillary Morin, who served as research coordinators.

less, it is frequently reported that substantial proportions of the popula-tion experience unresolved grief and clinical complications. Unresolvedgrief refers to extremes in the intensity or duration of grief symptoms(e.g., prolonged anguish and preoccupation with the loss or the completeabsence of reactions to the loss). Clinical complications refer to a varietyof associated problems such as anxiety, depression, health-compromis-ing behaviors, and physical morbidity sometimes leading to death(Jacobs & Kim, 1990; Osterweis, Solomon, & Green, 1984).

In a review of epidemiological studies, Jacobs (1993) concluded thatapproximately 20% of acutely bereaved individuals develop clinical com-plications. The percentage of outpatients in mental health clinics who ex-perience unresolved grief may be even higher. Estimates range from 15%to 33% (Lazare, 1979; Piper, Ogrodniczuk, Azim, & Weideman, 2001;Zisook & Lyons, 1989-1990; Zisook, Shuchter, & Schuckit, 1985). Be-cause unresolved grief and clinical complications frequently co-occur,they are often referred to collectively as complicated grief (CG).

The prevalence of CG is further increased because it is often a chroniccondition. This is particularly the case if it goes untreated (Rando, 1993).The high prevalence of complicated grief calls for cost-efficient treat-ments. Recent meta-analytic reviews of treatment outcome (Allumbaugh& Hoyt, 1999; Kato & Mann, 1999) have revealed that most treatmentshave been brief (8 sessions or fewer). However, the average effect sizeshave only been small to moderate. Explanations for these disappointingresults have included: insufficient intensity of treatment, lack of a theo-retical basis for treatment, considerable length of time before treatmentonset, methodological shortcomings of the research, and undetectedmoderator variables that result in high variation of outcome but onlymodest average outcome.

One of the most cost-effective forms of treatment in the mental healthfield is short-term group therapy (Fuhriman & Burlingame, 1994; Piper& Joyce, 1996). It is surprising how few examples of group treatments areincluded in the meta-analytic reviews or in Rando’s (1993) otherwisecomprehensive text on the treatment of complicated grief. There aremany examples of self-help groups in the literature, but only a few refer-ences to formal group therapies for complicated grief.

Since 1986, we have conducted a program in Edmonton, Canada, thatprovides time-limited, short-term group therapy to patients experiencingcomplicated grief (Piper, McCallum, & Azim, 1992). Sixteen of thesegroups were part of a controlled clinical trial that demonstrated their sta-tistical and clinical effectiveness (McCallum & Piper, 1990; Piper et al.,

526 PIPER ET AL.

1992). The theoretical orientation of the program is psychodynamic. Themajority of the more than 60 groups that have been conducted followedan interpretive (or expressive) technical approach that emphasized inter-pretation as a means of uncovering repetitive conflicts and trauma thatcontribute to maladaptation to loss. During the past 7 years, we have alsoconducted groups that followed a supportive technical approach thatemphasized support and problem solving to improve the patients’ imme-diate adaptation to their life situations. This has been consistent withgrowing interest in and use of supportive therapy in the psychotherapyfield (Novalis, Rojcewicz, & Peele, 1993; Pinsker, 1997; Rockland, 1989;Wallerstein, 1989). Because of their technical differences, supportivetherapy is generally considered to be less demanding, less depriving, andless anxiety arousing than interpretive therapy.

The present study investigated the interaction of two, theoretically rel-evant personality characteristics with the two forms of therapy (interpre-tive, supportive) for patients who met criteria for complicated grief. Thetwo personality characteristics, quality of object relations (QOR) and psy-chological mindedness (PM), have been cited frequently as important se-lection criteria for brief therapy (Lambert & Anderson, 1996). QOR re-fers to a person’s lifelong pattern of relationships, identified on adimension ranging from primitive to mature. PM refers to a person’sability to understand people and their problems in psychological terms.From a psychodynamic perspective, PM refers to the ability to identifycomponents of intrapsychic conflict. More complete definitions will beprovided in the method section under patient personality variables.

These two personality characteristics have been predictive of impor-tant clinical events (e.g., remaining, working, and benefiting) in a seriesof trials of individual and group psychodynamic psychotherapies that wehave conducted during the past 15 years (de Carufel & Piper, 1988; Piperet al., 1991; Piper Joyce, Azim, & Rosie, 1994; Piper, Joyce, McCallum, &Azim, 1998; Piper et al., 1992). In most of the trials, the therapies were in-terpretive in nature and the patients were a diagnostically mixed sampleof outpatients (e.g., mood and personality disorders), not a loss-specificsample.

The most recently completed of these trials (Piper et al., 1998) studiedthe interaction of each of the two personality characteristics with interpre-tive and supportive forms of individual therapy. It used a research designsimilar to the present trial. Overall, QOR was directly related to favorableoutcome in interpretive therapy and minimally related to outcome in sup-

COMPLICATED GRIEF 527

portive therapy. However, examination of the interaction at posttherapyand at one-year follow-up (Piper, McCallum, Joyce, Azim, & Ogrodniczuk,1999) revealed that for some variables, high-QOR patients did better in in-terpretive therapy, while for other variables low-QOR patients did betterin supportive therapy. We reasoned that patients with higher levels ofQOR may be better able to tolerate, work with, and benefit from the moredemanding aspects of interpretive group therapy. Conversely, patientswith lower levels of QOR may be better able to work with and benefit fromthe more gratifying aspects of supportive group therapy.

In contrast to QOR, PM was directly related to improvement in boththerapies. This finding had not been expected for supportive therapy.High-PM patients may have engaged in exploration of internal conflictsduring or outside of their supportive therapy sessions, or PM may reflecta general ability to analyze conflicts and solve problems whether the con-flicts are internal or external. PM may be valuable to many therapies.

On the basis of the above rationale and previous findings, we formu-lated two hypotheses. First, there will be an interaction effect betweenQOR and form of therapy. Higher levels of QOR will be associated withmore favorable outcome in interpretive therapy, and lower levels ofQOR will be associated with more favorable outcome in supportive ther-apy. Second, PM will be directly related to favorable outcome in boththerapies.

METHOD

Setting and Referrals

Patients were referred to the project from the walk-in clinic of the De-partment of Psychiatry, University of Alberta Hospital Site, Edmonton,Alberta, Canada. The clinic is part of a large, multifaceted, psychiatricoutpatient service that is located within a 600-bed university hospital. Ap-proximately 1,800 initial assessments are conducted in the clinic eachyear by a staff of eight from the disciplines of psychology, social work, oc-cupational therapy, and nursing. Approximately 18% of the patients areoffered some form of weekly psychodynamic psychotherapy (individual,couple, or group). A variety of other treatments are also offered, andsome patients are referred outside the clinic. Patients were referred ifthey met inclusion criteria for CG as described below. They were not re-ferred if a comorbid disorder would interfere with the patient’s ability tobenefit from group therapy (e.g., organic brain disorder), if a comorbid

528 PIPER ET AL.

disorder required immediate management and alternative treatment(e.g., severely depressed, manic, suicidal, or psychotic condition), or if adecision was made to treat a comorbid disorder first (e.g., simple phobiadisorder). During the referral period (October 1996-October 1999), anaverage of 5.2 patients per month were referred; that is, about 3.4% of allassessments and 19% of available psychodynamic psychotherapy cases.

Procedure

After an initial intake assessment, patients suspected of experiencingCG were scheduled for a second appointment to explore the possibilityin more depth. The death loss(es) had to occur at least three months pre-viously in order to exclude immediate grief reactions. If, during the sec-ond appointment, the assessor continued to believe that the patient wasexperiencing CG, group therapy was discussed as a treatment option, thepatient was scheduled for a third appointment, and the patient was askedto complete three brief questionnaires to determine whether the patientmet CG criteria. The questionnaires were a set of pathological grief items(PGI), adapted from work by Prigerson et al. (1995), the Impact of EventsScale (IES; Horowitz, Wilner, & Alvarez, 1979), and the Social Adjust-ment Scale—Self Report (SAS-SR; Weissman & Bothwell, 1976). The firsttwo scales (PGI, IES) were completed for the one or two most significantdeath losses in the patient’s life.

To meet the inclusion criteria, the patient had to have a score of 10 orhigher on the PGI, or the Intrusion subscale of the IES, or the Avoidancesubscale of the IES for at least one loss, and a score of at least 2.0 or higheron one of the six subscales of the SAS-SR. These criteria were selected, af-ter a review of previous studies, to include patients with at least moderategrief symptomatology and social (role) dysfunction. As indicated in theresults section, most patients who met the inclusion criteria considerablyexceeded the minimum requirements. If the inclusion criteria were met,at the third appointment the patient read a detailed information form,provided informed consent, and was referred to the research coordina-tor. Patients were scheduled for a set of pretherapy interviews and ques-tionnaire assessments that focused on predictor, demographic, diagnos-tic, and outcome variables. The assessors were unaware of the results ofeach other’s assessments. The research coordinator matched patients inpairs on the basis of their QOR score; PM score; use of medication; and,when possible, gender and age. Exact matches on the continuous QOR


and PM scales were not always possible. The best possible match wasachieved from the patients who were currently available. When 9 or 10pairs accumulated, one patient of each pair was assigned randomly to aninterpretive group and the other patient to a supportive group. Thematched pair of groups was assigned to a therapist who contacted the pa-tients and treated both groups during the same 12-week period. The pro-ject included 8 pairs of groups, that is, 16 groups in total. Soon after ther-apy ended, patients were reassessed on the outcome variables. A total of186 patients were referred to the project. Of these patients, 47 (25.3%)did not complete the pretherapy assessments and proceed to therapy;they were labeled decliners. Of the 139 patients who started therapy, 32(23%) attended less than 8 of the 12 group therapy sessions. They wereconsidered untreated and were labeled dropouts. An attempt was madeto replace dropouts with another matched patient through the secondsession. An attempt was also made to reassess dropouts at the same timeas the other patients in their groups. Of the 107 therapy completers(those who attended 8 or more sessions), 53 were from interpretive ther-apy and 54 were from supportive therapy.

Patients

All 107 treatment completers received diagnoses according to the re-vised third edition of the Diagnostic and Statistical Manual of Mental Disor-ders (DSM-III-R; American Psychiatric Association, 1987). Axis Idiagnoses were identified by the computer-administered Mini-Struc-tured Clinical Interview for DSM-III-R (Mini-SCID; First, Gibbon, Wil-liams, & Spitzer, 1990) and validated by an independent clinicaldiagnosis assigned jointly by the intake assessor and a psychiatrist, bothof whom saw the patient on the day of intake. A total of 73.8% of the pa-tients received an Axis I diagnosis. The most frequent disorders were cur-rent major depression (54.2%) and dysthymia (8.4%). Axis II diagnoseswere determined by the computer-administered Structured Clinical In-terview for DSM-III-R Personality Questionnaire (SCID-II PQ) andAuto-Structured Clinical Interview for DSM-III-R (Auto-SCID II; First,Gibbon, Williams, & Spitzer, 1991). Rater reliability for the Axis II diag-noses was calculated for nine randomly selected cases and three raters. Akappa was calculated for each pair of raters for each disorder. The meankappa for all pairs and disorders was .95. A total of 55.1% of the patientsreceived an Axis II diagnosis. The most frequent Axis II disorders were

530 PIPER ET AL.

avoidant (26.2%), dependent (13.1%), borderline (9.3%), and obses-sive-compulsive (4.7%). A total of 38.3% of the patients received bothAxis I and Axis II diagnoses.

The average age of the patients was 43.0 years (SD = 10.3, range =19-67). Seventy-seven percent were women. Forty-one percent were mar-ried or living with a partner, 26% were separated or divorced, 18% werewidowed, and 15% had never been married. Forty-seven percent were ed-ucated beyond high school, and 52% were employed. Ninety percent ofthe patients were Caucasian. Many (72%) reported receiving previouspsychiatric treatment, but few (15%) had a history of psychiatric hospital-ization. The types of losses reported by the patients and their prevalencewere: parent (45%), partner (14%), child (13%), sibling (12%), friend(3%), grandparent (4%), and other (9%). The average time since theloss(es) was 9.0 years (SD = 10.7, range = .25 - 47.0).

Therapists

The therapists were a 40-year-old male psychologist, a 41-year-old femalesocial worker, and a 40-year-old female occupational therapist. They hadsubstantial experience practicing group therapy (13, 14, and 10 years, re-spectively). The psychologist conducted four therapy groups and theother two therapists conducted six therapy groups each.

Therapies

Each patient received a form of group therapy that emphasized interpre-tive or supportive features. They were labeled interpretive therapy andsupportive therapy. The contractual and structural features were similar.The patient was scheduled for weekly 90-minute sessions for 12 weeks.Punctual attendance was emphasized. The therapist was paid by a thirdparty. Apart from these similarities, the overall objectives, session objec-tives, and therapist technique for the two forms of therapy were quite dif-ferent.

In interpretive therapy, the primary objective is to enhance the pa-tients’ insight about repetitive conflicts (intrapsychic and interpersonal)and trauma that are associated with the losses and that are assumed toserve as impediments to experiencing a normal mourning process. A re-lated objective is to help the patients develop tolerance for ambivalencetoward the people whom they have lost. The therapist attempts to createa climate of tolerable tension and deprivation wherein conflicts can be


examined through the use of here-and-now experience. In regard to tech-nique, the therapist encourages the patients to explore uncomfortableemotions and withholds immediate praise and gratification. The thera-pist is active, interpretive, and transference focused.

In supportive therapy, the primary objective is to improve the patients’immediate adaptation to their life situations. It is assumed that improve-ments in symptomatology and social (role) functioning can be achievedthrough the provision of support and problem solving. The therapist at-tempts to create a climate of gratification wherein patients can sharecommon experiences and feelings, and receive praise (reinforcement)for their efforts at coping. In regard to technique, the therapist is active,noninterpretive, and other focused (i.e., focused on the patients’ currentexternal relationships).

Session attendance for completers was high. For interpretive therapy,the mean was 10.7 (SD = 1.4). For supportive therapy, the mean was 10.6(SD = 1.3).

Treatment Integrity

The therapists were experienced in providing a variety of interpretiveand supportive therapies. Each had participated in a weekly seminar ofthe loss group program for many years and had conducted pilot groupsbefore conducting groups in this study. The seminar continued through-out the project. The therapists followed technical manuals for interpre-tive group therapy (Piper, McCallum, & Joyce, 1995) and supportivegroup therapy (McCallum, Piper, & Joyce, 1995a) for loss patients. Theydescribed, illustrated, and compared the technical emphases of the twoforms of group therapy.

All therapy sessions were audiotaped and observed through a one-waymirror. Adherence to the technical manuals was monitored by externalobservers (bachelor’s-level research assistants) using an Adherence scale(McCallum, Piper, & Joyce, 1995b). The scale consisted of 14 items (7 in-terpretive and 7 supportive) rated on a 5-point Likert-type scale rangingfrom 0 (no emphasis) to 4 (major emphasis) after the rater observed the en-tire session. The full-scale score, which is keyed in the interpretive direc-tion, ranged from 0 to 56. The rater reliability for the scale was assessedtwice during the project using the intraclass correlation coefficient (ICC;Shrout & Fleiss, 1979). The first assessment involved six raters and 12 ses-sions, and the second involved four raters and 12 sessions. The average

532 PIPER ET AL.

ICC (2,1) was .97. The scale’s internal consistency was assessed once. It in-volved six raters and 16 sessions. Cronbach’s α for the 14 items was .93.Adherence was monitored for all sessions. For the eight interpretivegroups, the mean full-scale score was 39.8 (SD = 2.7). For the eight sup-portive groups, the mean full-scale score was 14.5 (SD = 1.9). A t test com-paring these means was significant, t(14) = 21.35, p < .000. The evidencefrom the adherence ratings indicated that the two forms of therapy werewell differentiated and conformed to the technical manuals.

Medication

Management of medication was conducted by one of two project psychia-trists, who met with each patient before and after therapy. Fifty-nine(55.1%) of the 107 completers were prescribed a therapeutic dosage of apsychotropic medication prior to the start of the therapy groups. Innearly all cases (91.5%), the medication was an antidepressant (tricyclic,selective serotonin reuptake inhibitor, or other). For an antidepressant, atherapeutic dosage was defined as equivalent to 150 mg/day ofimiprimine for 6 weeks. In the remaining cases (8.5%), an anxiolytic,antipsychotic, or hypnotic was prescribed. Statistical analyses revealedno significant differences between the two forms of therapy in initial useor pattern of use during therapy.

Patient Personality Variables

Patients were matched on two personality variables—QOR and PM—be-fore being randomly assigned to one of the two therapies. QOR is definedas a person’s enduring tendency to establish certain types of relationshipsthat range along an overall dimension from primitive to mature (Azim,Piper, Segal, Nixon, & Duncan, 1991). A 9-point scale was used after aone-hour semistructured interview. The patient’s lifelong pattern of rela-tionships was explored in reference to criteria that characterize five levelsof object relations: primitive, searching, controlling, triangular, and ma-ture. The criteria refer to behavioral manifestations, regulation of affect,regulation of self-esteem, and historical antecedents. In regard to the twoextreme levels of the scale, mature object relations means the person en-joys equitable relationships characterized by love, tenderness, and con-cern for objects of both sexes. There is a capacity to mourn and tolerateunobtainable relationships. A tendency toward primitive object relationsmeans the person reacts to perceived separation or loss of the object, or


disapproval or rejection by the object, with intense anxiety and affect.There is inordinate dependence on the object, who provides a sense ofidentity for the person. The interviewer, who followed a scoring manual(Piper, Joyce, & McCallum, 1993), assigned 100 points along the five levelsof the scale and an overall score that ranged from 1 to 9. Two psychologistsand three psychiatrists served as raters. The rater reliability for the scalewas assessed during three periods of the project (beginning, middle, end).Each assessment involved the five raters and 12 patients. The average ICC(2, 1) for the three assessments was .83.

PM is defined as the ability to identify dynamic (intrapsychic) compo-nents and relate them to a person’s difficulties (McCallum & Piper,1997). The interview assessment differentiates nine levels of PM. It is in-dividually administered and takes approximately 15 minutes. A video-tape presents two simulated patient-therapist interactions (scenarios).Each begins with an actress-patient describing a recent event to her thera-pist. In Scenario 1, the patient describes seeing her former husband froma distance. In Scenario 2, the patient describes an argument with her boy-friend. After viewing each scenario, the person being assessed is asked,“What seems to be troubling this woman?” The person’s responses arescored according to how well they reflect basic assumptions ofpsychodynamic theory and the ability to identify dynamic components.The two extremes are Level 9, which indicates that the person recognizesthat the patient is engaging in a defensive maneuver but remains dis-turbed by the conflict, and Level 1, which indicates that the personmerely identifies a specific internal experience of the patient. The inter-viewer, who followed a scoring manual (McCallum & Piper, 1987), as-signed an overall score from 1 to 9 to each of the two scenarios.

One of six bachelor’s-level assistants assessed PM for each patient.Rater reliability was also assessed during three periods of the project (be-ginning, middle, end). Each involved the six raters and 12 patients. Theaverage ICC (2, 2) was .81 for Scenario 1 and .88 for Scenario 2. The Sce-nario 1 score was used as the matching score, and the Scenario 1 and 2scores were used as predictor scores. The correlation between the twoscenario scores was significant and moderate, r(105) = .45, p < .001.

Outcome Variables

Assessment of outcome included 14 measures (questionnaire or inter-view) that covered 15 variables in the areas of grief symptoms, interper-

534 PIPER ET AL.

sonal distress, social (role) functioning, psychiatric symptoms,self-esteem, life satisfaction, and physical functioning. Severity of distur-bance for individual target objectives was also assessed.

Grief symptoms were measured by seven pathological grief items(Prigerson et al., 1995), the 7-item Intrusion Subscale and the 8-itemAvoidance subscale of the IES (Horowitz et al., 1979), and the 13-itemPresent Feelings subscale of the Texas Revised Inventory of Grief (TRIG;Faschingbauer, Zisook, & DeVaul, 1987). These three scales were com-pleted for the one or two most significant death losses in the patient’s life.If there were two losses, the scores were averaged.

The overall score from the 64-item Inventory of Interpersonal Prob-lems (Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988) was usedto measure interpersonal distress. The overall score from the 54-itemSAS-SR (Weissman & Bothwell, 1976) was used to measure social (role)functioning. For psychiatric symptomatology, depression was assessedby the 21-item Beck Depression Inventory (Beck & Steer, 1987); anxiety,by the 20-item Trait Anxiety Scale (Spielberger, 1983); and general symp-tomatic distress, by the Global Severity Index of the 53-item Brief Symp-tom Inventory (Derogatis, 1993). Self-esteem was measured byRosenberg’s (1979) 10-item Self-Esteem Scale. Life satisfaction was mea-sured by a single item rated on a 7-point Likert-type scale that rangedfrom 1 (completely dissatisfied) to 7 (completely satisfied). Physical function-ing was assessed by the 10-item Physical Functioning subscale of theSF-36 Health Survey (SF-36; Medical Outcomes Trust, 1994). Individual-ized target objectives were formulated by the patient with the assistanceof an independent assessor (bachelor’s-level research assistant). The pa-tient’s average rating, the independent assessor’s average rating, and thetherapist’s average rating of severity of disturbance for the objectiveswere used as outcome scores. Two rater reliability determinations for theassessor’s rating, using six raters and 12 cases each, yielded an averageICC (2,1) of .96, indicating high reliability. A content analysis of the objec-tives revealed that 70% of the patients made explicit reference to loss inone or more of their objectives; for example, “To be able to talk about mydad without tears coming to my eyes.”

Calculation of residual change scores.

Residual change scores (pretherapy to posttherapy) were calculated foreach of the 15 outcome variables. The scores represent change with the


influence of the prescore on the postscore removed. Because of moder-ate to high correlations among the scores, a principal-components analy-sis with orthogonal rotation was used to reduce the 15 variables to asmaller number of outcome factors. Three factors (eigenvalues > 1)emerged, which accounted for 67% of the variance. The factors (generalsymptoms, grief symptoms, and target objective severity and life dissatis-faction) and their corresponding outcome variables and loadings arelisted in Table 1.

RESULTS

Approach to Analysis

First, the two hypotheses of the study were tested by investigating the in-teraction effect of QOR and form of therapy, and the main effect of PM

536 PIPER ET AL.

TABLE 1. Outcome Factors, Variables, and Loadings

Outcome factor and variable Loading

General Symptoms (31% of variance)

Anxiety .84

Depression .83

Interpersonal distress .81

Self-esteem .81

General symptomatic distress .77

Social (role) dysfunction .69

Physical dysfunctiona -.56

Grief Symptoms (19% of variance)

Intrusion .86

Pathological grief .84

Grief (TRIG) .75

Avoidance .68

Target Objective Severity and Life Dissatisfaction (17% of variance)

Target severity (therapist) .76

Target severity (assessor) .70

Target severity (patient) .66

Life dissatisfactiona -.61aHigh scores are favorable. TRIG = Texas Revised Inventory of Grief.

on the outcome factors. The criterion of statistical significance was usedwith the completer sample and an intent-to-treat sample. In addition, thecriterion of clinical significance and reliable change was used with thecompleter sample. Second, outcome change over the course of therapywas investigated for each form of therapy. Third, dropouts were brieflyexamined.

Testing of Hypotheses

Statistical Significance (Completer Sample). To investigate the interactioneffect, we conducted a three-step, hierarchical regression analysis foreach of the three outcome factors. Treatment (interpretive vs. support-ive) was entered first, then QOR, and then the interaction product. As in-dicated in Table 2, for the grief symptoms factor, a significant interactioneffect for treatment and QOR was found. For interpretive therapy, thehigher the QOR, the better the outcome; for supportive therapy, thehigher the QOR, the worse the outcome. We further investigated the in-teraction effect with an ANOVA model in which patients were dividedinto high (≥ 4.0) and low (< 4.0) QOR groups. Tukey’s honestly signifi-cant difference (HSD) post hoc comparison method revealed thathigh-QOR patients improved significantly more in interpretive therapythan in supportive therapy, Q(90) = 4.68, p < .01. Low-QOR patients im-proved significantly more in supportive therapy than in interpretive ther-apy, Q(90) = 4.16, p < .05.

Similarly, for the general symptoms factor, a significant interaction ef-fect was found. For interpretive therapy, the higher the QOR, the betterthe outcome, and for supportive therapy, the higher the QOR, the worsethe outcome. Using an ANOVA model, Tukey’s HSD method revealedthat high-QOR patients improved significantly more in interpretive ther-apy than in supportive therapy, Q(91) = 6.03, p < .01. There was not a sig-nificant difference for low-QOR patients. The interaction effectsuperceded a main effect for treatment, which favored interpretive ther-apy. There were no significant effects for the target objective severity andlife dissatisfaction factor.

A similar hierarchical regression analysis was conducted using each ofthe two PM scores (Scenario 1 and Scenario 2) at the second step of theanalysis. For Scenario 1, only the main effect for the grief symptoms fac-tor was significant, F(1,91) = 7.55, p < .007. It indicated a direct relation-ship between PM and favorable outcome. There were no significant ef-


538 PIPER ET AL.

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fects for Scenario 1 for the general symptoms factor or the targetobjective severity and life dissatisfaction factor. For Scenario 2, therewere no significant effects for the three factors.

Statistical Significance (Intent-to-Treat Sample). A more conservative ap-proach to testing one’s hypotheses is to use an intent-to-treat procedure.This involves testing hypotheses on a sample that includes all subjectswho began treatment, not just completers. The procedure assumes thatmissing data from subjects who did not complete treatment are not ran-dom and that an analysis of data that is based only on treatment complet-ers could produce biased estimates of treatment effects. In the presentstudy, the intent-to-treat sample included all 139 patients who begantreatment. Missing post-therapy data for patients who dropped out oftreatment were replaced with their pre-therapy scores. The procedure as-sumes no treatment effect for the 32 drop-out patients.

The three-step hierarchical regression analyses described above wererepeated using the intent-to-treat sample. Similar to the completer sam-ple analyses, we found a significant interaction effect between QOR andform of therapy for the grief symptoms factor, F(1,135) = 4.20, p = .042,and the general symptoms factor, F(1,134) = 4.16, p = .043. In addition,we again found a main effect of PM for the grief symptoms factor F(1,136) = 3.84, p = .052. Thus, the results found when using the completersample were similar to those found using the more conservative in-tent-to-treat procedure.

Potential Confounding Variables. Three potentially confounding factors inthese analyses were the variables representing the therapist, the use ofmedication, and the group. No significant differences were found amongthe three therapists for each of the outcome factors. Similarly, no signifi-cant differences were found on the outcome factors between patientswho were prescribed therapeutic dosages of psychotropic medicationand those who were not. In contrast, a significant difference was foundamong the 16 groups on the grief symptoms factor. However, the effectwas small (one of the interpretive groups differed from two of the otherinterpretive groups), and when the hierarchical regression analyses wererepeated with group entered at the first step, the findings reported abovechanged negligibly and remained significant.

Clinical Significance and Reliable Change. Clinical significance refers towhether the amount of change for a patient is clinically important as de-termined by norms. Reliable change refers to whether the amount of


change exceeds measurement error. These two criteria were calculatedfor three of the outcome variables (depression, anxiety, and generalsymptomatic distress) of the general symptoms factor that have consider-able normative data. Comparable data do not exist for the variables ofthe grief symptoms factor. The two-part procedure (clinical cut-off crite-rion and reliable change index) developed by Jacobson and colleagues(Jacobson, Follette, & Revenstorf, 1984; Jacobson & Revenstorf, 1988; Ja-cobson & Truax, 1991) and refined by others (Christensen & Mendoza,1986; Tingey, Lambert, Burlingame, & Hansen, 1996) was used. Accord-ing to the first part, a patient must move from a dysfunctional range pasta cut-off value to a functional range on an outcome variable. Accordingto the second part, a patient must change by a reliable amount, takinginto account measurement error.

For the Beck Depression Inventory, Beck and Steer (1987) reported amean of 23.6 for 168 patients with recurrent major depression, andNietzel, Russell, Hemmings, and Gretter (1987) reported a mean of 7.2for a large sample of collegiate/general population participants from 12studies. For the Trait Anxiety Scale, Spielberger (1983) reported a meanof 48.1 for 60 anxiety reaction patients and a mean of 34.8 for 451 femaleworking adults. For the global severity index of the Symptom DistressChecklist-Revised (SCL-90-R), Derogatis (1977) reported a mean of 1.26for 1,002 psychiatric outpatients and a mean of .31 for 974 nonpatients.As indicated in Table 3, the pretherapy means of the interpretive andsupportive patients in the present study considerably exceeded the re-ported dysfunctional norms for these three outcome variables, whichclearly confirmed the clinical nature of the sample. Because of this, thepretherapy means rather than the dysfunctional norms were used to cal-culate the clinical significance and reliable change criteria.

Using Jacobson and Revenstorf’s (1988) formula, the clinical cut-offcriteria were 14.7 for the Beck Depression Inventory, 45.2 for the TraitAnxiety Scale, and .71 for the Global Severity Index. Only patients whosepretherapy scores were above the criteria were considered. The numbersof such patients were similar between the two therapy conditions. For in-terpretive and supportive therapy, respectively, there were 42 and 41 pa-tients for the Beck Depression Inventory, 42 and 42 patients for the TraitAnxiety Scale, and 43 and 42 patients for the Global Severity Index. Inthe case of interpretive therapy, the percentages of patients who tra-versed the criteria were 40.5%, 38.1%, and 34.8%, respectively. In the

540 PIPER ET AL.


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case of supportive therapy, the percentages of patients who traversed thecriteria were 19.5%, 16.7%, and 16.7%, respectively. These percentagesare summarized in Table 4.

According to the modified formula of Jacobson and Revenstorf (1988;as reported in Tingey et al., 1996), the reliable change indices were 11.7for the Beck Depression Inventory, 10.6 for the Trait Anxiety Scale, and.71 for the Global Severity Index. The percentages of interpretive ther-apy patients who achieved reliable change were 39.5%, 34.0%, and37.8%, respectively. The percentages of supportive therapy patients whoachieved reliable change were 30.2%, 22.9%, and 27.3%, respectively.

Finally, the percentage of patients who both traversed the clinical cut-off criteria and achieved reliable change was calculated. In the case of in-terpretive therapy, the percentages were 28.6% (Beck Depression Inven-tory), 33.3% (Trait Anxiety Scale), and 30.2% (Global Severity Index). In

542 PIPER ET AL.

TABLE 4. Percentages of Clinical and Reliable Improvement fromPretherapy to Posttherapy for Three Outcome Variables for

Interpretive Therapy and Supportive Therapy

Therapy:Outcome Variable Category

Percentage ofPatients that Improved

Interpretive: Clinical improvement 40.5

Depression Reliable improvement 39.5

Clinical and reliable improvement 28.6

Supportive: Clinical improvement 19.5

Depression Reliable improvement 30.2



Anxiety Reliable improvement 34.0



Anxiety Reliable improvement 22.9



Distress Reliable improvement 37.8



Distress Reliable improvement 27.3


the case of supportive therapy, the percentages were 14.6%, 11.9%, and11.9%, respectively.

To test for main and interaction effects involving clinical significanceand reliable change, a three-step, hierarchical, logistic regression analysiswas conducted for the frequency of patients who achieved both clinicalsignificance and reliable change for each of the three outcome variables.Treatment was entered first, then a personality variable (QOR or PM Sce-nario 1 or PM Scenario 2), and then the interaction product. From theseanalyses, the log-likelihood tests revealed two significant main effects fortreatment. For anxiety χ2(1,N = 84) = 5.69, p = .017 and general symptom-atic distress, χ2(1,N = 85) = 4.40, p = .036, the frequency of patients whoachieved both clinical significance and reliable change was higher in in-terpretive than supportive therapy.

Change Over the Course of Therapy

Statistical Significance. Correlated t tests were used to investigate statisti-cally significant change during therapy for patients in each form of ther-apy for the 15 outcome variables. A Bonferroni corrected α level of .003(.05/15) was used. For interpretive therapy, 12 of the 15 variablesshowed significant improvement. Only interpersonal distress, target ob-jective severity as rated by the therapist, and physical functioning did not.For supportive therapy, 7 of the 15 variables showed significant improve-ment, including all four of the grief symptom variables. Thenonsignificant variables included: anxiety, self-esteem, interpersonal dis-tress, general distress, social adjustment, life satisfaction, target objectiveseverity as rated by the therapist, and physical functioning.

Magnitude of Effect. In contrast to statistical significance, the criterionknown as magnitude of effect directly expresses the size of impact thatone variable has on another, in our case, therapy on outcome. Magnitudeof effect was investigated by calculating an effect size for each of the 15variables for each form of therapy according to the formula provided byCohen (1988): Effect size = pretherapy mean - posttherapy mean /pretherapy standard deviation. The effect sizes are listed in Table 3. Forinterpretive therapy, the average effect size for all 15 variables was .75.This means that the average patient at posttherapy was better off than77% of the patients at pretherapy. The average effect sizes for the vari-ables within the three outcome factors were: .98 for grief symptoms, .53for general symptoms, and .91 for target objective severity and life dissat-


isfaction. For supportive therapy, the average effect size for all 15 vari-ables was .50. This means that the average patient at posttherapy wasbetter off than 69% of the patients at pretherapy. The average effect sizesfor the variables within the three outcome factors were: .79 for griefsymptoms, .24 for general symptoms, and .67 for target objective severityand life dissatisfaction. In general, the largest effect sizes were for targetobjectives (rated by the patient and independent assessor), which oftenfocused on loss, and grief symptoms, followed by general symptoms. Theeffect sizes for interpersonal distress, social (role) dysfunction, and physi-cal dysfunction were relatively small. The effect sizes for the therapist’sseverity rating for target objectives were also small, but negative.

Dropouts

Of the 32 dropouts, 15 (22%) were from interpretive therapy and 17(24%) were from supportive therapy. Thus, the frequencies and percentsfor the two therapies were nearly the same. Neither QOR nor PM was re-lated to dropping out, nor was the interaction between each of these per-sonality characteristics and form of therapy. Most dropouts (80% ininterpretive therapy and 71% in supportive therapy) left during the firstthird of therapy. Unfortunately, the compliance of the dropouts with re-assessment on the outcome variables was poor, with only 5 of the 32dropouts providing complete data.

DISCUSSION

The findings provide information about the impact of QOR and PM ontreatment outcome for two forms of time-limited, short-term group ther-apy (interpretive, supportive) for patients who met criteria for compli-cated grief. It is apparent that the findings differ according to severalfactors. In addition to form of therapy and patient personality, they de-pend on the particular type of outcome (general symptoms, grief symp-toms, target objectives and life dissatisfaction), and the particular type ofstatistical criteria (statistical significance, clinical significance and reliablechange, magnitude of effect).

Given the number of factors and findings, it is important to keep inmind that the primary purpose of the therapy groups was to assist pa-tients with difficulties in adapting to the losses of people in their lives.Most patients did not present to the clinic with complaints about loss.However, over the course of the initial interviews, loss issues were identi-

544 PIPER ET AL.

fied, inclusion criteria were met, and a mutual decision was made that thepatient would participate in a group therapy program for loss. In thiscontext, findings concerning grief symptoms are particularly relevant.

For the grief symptoms outcome factor, evidence was found that sup-ported both initial hypotheses. A significant interaction effect was foundfor QOR and form of therapy. High-QOR patients had significantlybetter outcome in interpretive therapy and low-QOR patients had signifi-cantly better outcome in supportive therapy. Because of their history ofmore satisfactory give-and-take relationships, high-QOR patients mayhave been better able to tolerate and work with the more demanding, de-priving, and anxiety arousing features of interpretive group therapy, in-cluding the examination of painful conflicts and their relationships to thelost persons. Their greater ability to tolerate ambivalent feelings towardothers likely facilitated this process. Also, they may have been less appre-hensive about the inevitable ending of the time-limited group and moreable to invest in working relationships with others in the group. In con-trast, given their history of relatively unsatisfactory relationships,low-QOR patients may have found that the gratifying features of support-ive therapy better met their immediate interpersonal needs. This mayhave enabled them to become more involved in the supportive process ofproblem solving regarding everyday difficulties.

Also as predicted, PM was directly related to favorable outcome on thegrief symptoms factor for both forms of therapy. In interpretive therapy,where the exploration on internal conflicts is emphasized, the usefulnessof PM is clear. In supportive therapy, it is possible that high-PM patientswere more engaged in exploring internal conflicts and their relationshipsto their losses during their therapy sessions or outside of their sessionsthan low-PM patients, despite the lack of emphasis on these issues by thetherapist. In group therapy, patients have considerable influence onwhat is discussed in sessions. Alternatively, PM may reflect a useful gener-al ability to examine conflicts and solve problems, whether the conflictsare internal, as emphasized and explored in interpretive therapy, or ex-ternal, as emphasized and explored in supportive therapy.

The findings for the general symptoms factor provided further sup-port for the interaction between QOR and form of therapy. High-QORpatients had significantly better outcome in interpretive therapy than insupportive therapy. As suggested above, the greater ability to tolerateand work with the features of interpretive group therapy may have pro-vided them with a particular advantage.


The results concerning magnitude of effect provide informationabout the efficacy of the two forms of therapy. The average effect size forinterpretive therapy (.75) was large, while the average effect size for sup-portive therapy (.50) was moderate. However, there was considerablevariability among the outcome factors and variables. Relevant to the pri-mary focus of the loss groups, the effect size for the grief symptoms factorwas large for both forms of therapy, although a little larger for interpre-tive therapy. Similarly, the effect sizes for the other two factors werelarger for interpretive therapy, although in general smaller than the ef-fect sizes for the grief symptoms factor.

At the level of specific outcome variables, some had quite small effectsizes; for example, interpersonal distress, social (role) dysfunction, andphysical dysfunction. It is possible that time-limited loss groups simply donot provide the intensity or focus necessary to achieve substantial im-provement in these areas. Target objective severity as rated by the thera-pist also had small effect sizes in contrast to the ratings provided by thepatient and independent assessor. It is possible that the therapist’s ratingwas not reliable or valid. In contrast to the patient and independent asses-sor, who had considerable opportunity to carefully review the severity ofdisturbance for target objectives as part of their conjoint assessment in-terview, the therapist was forced to estimate severity indirectly from thegeneral process of the group. Given that each patient had several objec-tives and there were up to ten patients in each group, the task involvedconsiderable inference.

An advantage for interpretive therapy was also evident in the percent-ages of patients who achieved both clinical significance and reliablechange. Significantly higher percentages were found for interpretivetherapy for both anxiety and general symptomatic distress. Although notgrief symptoms, the findings suggest an additional benefit from interpre-tive therapy. However, even in interpretive therapy the percentages werenot particularly high (just over 30%). Again, this may be related to the factthat the treatment was brief (total of 18 hours) and these outcome vari-ables were not the focus of treatment.

Several clinical implications follow from the findings. The interactioneffects involving QOR and form of therapy suggests that QOR might be auseful, patient selection criterion for loss groups. Patients with higherQOR scores could be referred to interpretive groups, while patients withlower scores could be referred to supportive groups. The one-hour inter-view assessment of QOR in the present study is reliable and practical. It

546 PIPER ET AL.

could be integrated with the assessment of the patient’s history, which isroutinely reviewed in most clinics and practices. A consequence of usingQOR as a selection criterion would be the creation of more homoge-neous patient compositions in the therapy groups. This might result ineven better outcome, because patients would be more inclined to work insimilar ways. Further research is needed to test this possibility.

The findings also suggest that improvement can be enhanced for ei-ther therapy by selecting patients with higher PM scores. PM appears tohave a beneficial effect regardless of the nature of the conflicts and diffi-culties being explored in therapy. A particular advantage of the assess-ment of PM is its brevity, approximately 15 minutes. Although it does re-quire a videocassette recorder and monitor, such equipment is becomingmore commonplace in modern clinics and offices.

The present study is characterized by strengths and limitations.Strengths include use of a randomized clinical trial design, a large clinicalsample, a comprehensive set of outcome criteria, experienced therapists,therapy manuals, and adherence checks. Also, the hypotheses were gen-erated on the basis of theory (psychodynamic) and previous findingsfrom psychotherapy clinical trials conducted by the investigators. Thefact that the QOR interaction effect findings and the PM main effect find-ings resembled findings from a recently completed and similarly de-signed trial of time-limited, short-term individual therapies with a differ-ent patient sample (Piper et al., 1998), suggests that the hypotheses maygeneralize to different types of psychodynamic therapies.

In regard to limitations, some of the findings (e.g., the QOR interac-tion effects) may only generalize to psychodynamic therapies that havedistinct technical differences on interpretive and supportive dimensions.Other characteristics of the patients, therapists, and therapies may alsolimit generalization. Most patients did not include grief as part of theirpresenting complaints to the clinic. This would seem to suggest that thesample may differ in level of grief disturbance—from patients who dopresent with grief as a presenting complaint. That may be true. However,prevalence studies indicate that most patients with complicated grief donot include it as a presenting complaint, which suggests that our sampleis representative of most patients. In addition, the patients were fairlywell educated, were primarily Caucasian, and represented only a subsetof all the patients treated at the clinic. The therapists were experiencedand accustomed to providing manual-guided therapies. The therapieswere time-limited and brief. In addition, the total amount of variance ac-


counted for by the independent variables was modest (8%-9%), as indi-cated in Table 2. Obviously, other as yet undetected variables influencethe outcome of patients with complicated grief. The study did not in-clude a control condition. Although a previous controlled study (Piper etal., 1992) with a similar sample demonstrated evidence of the efficacy ofthe interpretive form of group therapy, it would have been desirable toinclude a control condition in the present study. In the present study, theuse of medication was controlled through the procedure of matching,but it was not manipulated as an independent variable. Thus, the main ef-fect of medication and its possible interactions with the therapies andpersonality variables of the present study cannot be determined.

Finally, the results of the present study do not include process datathat might illuminate some of the mechanisms underlying the findings,and the results are limited to outcome assessed soon after therapy ended.Currently, we are examining aspects of therapy process, which may pro-vide information concerning mechanisms of change.

Despite the acknowledged limitations of the present study, we believethat it provides support for the usefulness of time-limited, short-termtherapy groups for patients who have difficulties adapting to loss. Wealso believe that the study provides evidence for a potentially importantmatch between patient personality (QOR) and different forms of dynam-ically oriented group therapies. The search for optimal patient-treatmentmatches in the psychotherapy literature has met with mixed success(Shoham-Salomon, 1991). As the present study illustrates, optimalmatches may be restricted to specific patient variables, therapies, out-come variables, and change criteria. We believe that the present studyprovides support for continuing efforts to discover such matches.

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Dr. William Piper Received: December 6, 2000Department of Psychiatry Accepted: January 24, 2001University of British Columbia2255 Wesbrook MallVancouver, BC V6T 2A1Canada

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