Death Studies, 39: 165–172, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 0748-1187 print=1091-7683 online
DOI: 10.1080/07481187.2014.946627

Common Therapeutic Factors in Bereavement Groups

Alexander Rice
College of Education, University of Iowa, Iowa City, Iowa, USA

Group therapy remains a popular treatment format for individuals experiencing

bereavement. Although many innovative group treatments for grief are being
developed, common therapeutic factors can also contribute to outcomes. The author
integrates research on group therapy processes and treatment for grief, and examines
evidence regarding group therapeutic factors that may influence bereavement group
outcomes. Specifically, research on therapeutic factors related to sharing and support,
interpersonal learning, and meaning-making is highlighted where it has relevance to
bereavement groups. Potential research examining the interactions of these processes,
their effects on group functioning and outcomes, and the moderators of these effects
are discussed.

Bereavement groups are attended by a wide range of specific grief treatments (e.g., cognitive behavioral or
individuals in the community and have seen growth interpersonal groups), less attention has been given to
due to burgeoning online participation (Altmaier, nonspecific therapeutic factors that could potentially
2011; Feigelman, Gorman, Beal, & Jordan, 2008). This mediate outcomes of bereavement groups (Piper,
public interest in bereavement group continues unabated Ogrodniczuk, Joyce, & Weideman, 2009). The present
despite question about the effectiveness of bereavement purpose is to review the research on group therapeutic
treatment. Based on meta-analytic findings, some factors relevant to bereavement groups and suggest
researchers have argued that treatment for grief is gener- directions for future research. As group members with
ally ineffective except for a small subset of individuals and without CG disorder may benefit from factors that
who have complicated grief (CG) disorder. CG disorder do not specifically target pathological grief symptoms,
has been defined as a pathological grief response marked I will consider therapeutic factors with the potential
by symptoms including chronic and disruptive yearning to improve well-being (e.g., increasing self-esteem and
for the deceased, thoughts that life is meaningless, lack reducing loneliness and isolation, distress, depression,
of hope for the future, avoidance of reminders of the and anxiety) in addition to those that affect pathological
deceased, and difficulty in functioning or adapting to grief symptoms.
the loss (Bonanno, Boerner, & Wortman, 2008; Currier,
Neimeyer, & Berman, 2008; Jordan & Neimeyer, 2003).
Bereavement groups show promise in the treatment of THERAPEUTIC FACTORS IN GROUPS
CG and may even have value in providing short-term
relief and improving well-being among those who seek The group therapy literature describes a number of
treatment but do not manifest CG responses (Currier therapeutic factors that may have relevance for bereave-
et al., 2008; Kang & Yoo, 2007; Wittouck, Van Autreve, ment groups. In one of the most comprehensive and
De Jaegere, Portzky, & van Heeringen, 2011). influential reviews of research on group therapeutic fac-
Although much of the research on bereavement tors, Yalom and Leszcz (2005) described 11 interrelated
treatment effectiveness has focused on the outcomes of therapeutic factors that contribute to group therapy out-
comes. Those factors most relevant to research on
Received 26 January 2014; accepted 17 June 2014. bereavement groups will be discussed here, clustered
Address correspondence to Alexander Rice, College of Education, into three groups: (a) social support, including cohesion
University of Iowa, N459 Lindquist Center, Iowa City, IA 52242 and altruism; (b) interpersonal learning and attachment;
E-mail: [email protected]
166 A. RICE

and (c) meaning-making of their loss. Because of space can be richer than in individual therapy due to the
limitations, this is not an exhaustive review of all greater number of sources of support. In fact, numerous
processes likely to impact bereavement group outcomes. findings suggest that social support is one of the strongest
I chose these three factors because of their prominence predictors of group outcomes (see Harel, Shechtman, &
in the bereavement literature and potential importance Cutrona, 2011). A number of processes in bereavement
in group settings. Given that these factors are not spe- groups might influence the effect of social support, such
cific to a treatment modality, I assumed here that they as cohesion, universality, altruism, and group pressure
have the potential to influence, at least to some extent, to change (Piper et al., 2009). For example, cohesion
any type of bereavement group, including support refers to the quality of the interrelationships between
groups, interpersonally focused groups, and cognitive the group members, group leaders, and the group as a
behavioral therapy groups, until research suggests whole (Burlingame, McClendon, & Alonso, 2011).
otherwise. Group cohesion has a strong positive relationship with
treatment outcomes in general therapy groups and
bereavement groups (Gallagher et al., 2013). Further,
Social Support
group cohesion is associated with lower dropout rates,
One of the primary reasons people seek out bereavement increased hope for the future, and higher self-esteem
groups of any kind is to discuss concerns related to among group members with CG (Marmarosh, Holtz, &
bereavement and share support around these concerns. Schottenbauer, 2005; McCallum, Piper, Ogrodniczuk, &
Picton, Cooper, Close, and Tobin (2001) found that Joyce, 2002). Further, universality (knowledge that others
the reasons bereavement group members gave for join- share similar thoughts, problems, feelings, or have coped
ing the group all involved sharing and support. These with similar experiences) and altruism (opportunities to
included the need for emotional support, sharing grief support each other with advice, or help with solving
experiences with others who have gone through similar problems) are common processes in bereavement groups
experiences, and a perceived absence of adequate family and can facilitate group engagement and improve treat-
support. Bereavement group members commonly share ment outcomes (Brown, Brown, House, & Smith, 2008;
and support each other during groups (Finley & Payne, Picton et al., 2001; Umphrey & Cacciatore, 2011).
2010; Umphrey & Cacciatore, 2011). Although supportive processes may have an impor-
Cognitive stress theories posit that bereavement gen- tant role in bereavement groups, few studies have
erates stress that is greater than a person’s perceived looked at the factors affecting level of social support
ability to cope (Folkman, Lazarus, Dunkel-Schetter, provided by group members. One exception is Piper,
Delongis, & Gruen, 1986; Orgodniczuk, Joyce, & Piper, Ogrodniczuk, Joyce, Weideman, and Rosie (2007),
2003). As people use social support when judging their which compared outcomes of a number of supportive
ability to cope, bereaved individuals may seek social and interpretative interpersonal therapy groups for indi-
support in an attempt to assuage overwhelming feelings viduals with CG. Groups comprised of a larger pro-
of loss and=or increase their perceived ability to cope portion of individuals with a history of high quality
with those feelings. interpersonal relationships (termed quality of object
However, it is unclear from the research whether or relations) had better grief outcomes than others. This
not social support actually affects the course of grief. finding applied to support groups as much as interpret-
A review of the literature on the effect of support on ative interpersonal therapy groups, suggesting that the
grief symptoms determined that social support can result was likely due to individuals with a high quality
improve the general wellbeing of individuals following of object relations (QOR) providing increased support.
bereavement, but it is not differentially effective in The researchers suggested that the high QOR group
reducing grief symptoms (Stroebe, Schut, & Stroebe, members interacted in a mutually beneficial way with
2005). Other research disagrees. In a recent study of all participants, providing high quality support to group
African Americans bereaved by homicide, those who members, thus improving grief outcomes. In a follow-up
reported more social supports had fewer symptoms of study, participants who did not improve in grief out-
CG (Burke, Neimeyer, & McDevitt-Murphy, 2010). comes posttreatment, but did improve at 6 months, also
However their perceived level of social support was had associated increases in the social support they
unrelated to their symptoms of CG. The authors con- received from friends and relatives posttreatment. Thus,
cluded that awareness of supportive others may have a it appears that group-provided social support may have
more soothing effect on grief than the specific support influenced members to seek greater support outside the
provided. group, which subsequently contributed to long-term
Most studies examining the effect of social support grief recovery.
on grief have not looked at the social support provided Although these results suggest that complicated grie-
in a group treatment setting. Social support in groups vers may benefit from group-provided social support,
 COMMON THERAPEUTIC FACTORS IN BEREAVEMENT GROUPS 167

they conflict with an earlier study that found that social memories of the deceased with realizations that the
support from family members, friends, and someone person is gone, allowing reorganization of the attach-
described as special to the bereaved person was associa- ment bond, and relationships with others. Deactivating
ted with fewer symptoms of depression, but not grief, at strategies contribute to reorganization through enabling
6 months posttreatment (Ogrodniczuk et al., 2003). detachment from the deceased and suppression of pain-
Therefore, it is not yet clear if supportive group pro- ful thoughts and feelings.
cesses can improve symptoms of CG, or facilitate treat- Hyperactivating and deactivating systems could pro-
ment of CG, although the evidence certainly supports duce problematic grieving responses. Hyperactivating
the idea that supportive group processes can improve strategies could become overwhelming when the person
associated outcomes such as depression. who was lost was unavailable or rejecting when alive or
when other relationship partners are unresponsive or
emotionally distant. Anxiously attached individuals
Interpersonal Learning and Attachment
who commonly experience discomfort around self-
As group members share concerns and support one autonomy would likely experience strong hyperactivating
another, they also have unique opportunities to interact strategies, and weak deactivating strategies to help
in new ways (Umphrey & Cacciatore, 2011; Yalom & counter the experience of painful thoughts, feelings,
Leszcz, 2005) and develop new interpersonal interaction and memories related to the loss. Avoidant individuals
patterns. Changes in attachment (the emotional bond who often distance themselves from thoughts and feel-
individuals form with others) might occur as the sup- ings related to relationships and suppress attachment
portive group environment meets some of the emotional ties are likely to experience more deactivating than
needs of group members. Interpersonal learning results hyperactivating strategies (Shaver & Mikulincer, 2002).
when group members gain new insights about their As emotional bonds often form between group mem-
internal working models of relationships, reflect on their bers, it is likely that the bereavement groups will also
style of interpersonal interaction as elicited by the elicit hyperactivating and deactivating strategies. These
group, and practice new interpersonal behaviors strategies may occur among noncomplicated grievers,
(Conyne, 2012). particularly if they attend the group relatively soon after
Interpersonal group processes may be particularly the loss. However, individuals with CG responses
relevant for group members with CG, which is associa- characteristic of avoidant or anxious attachment may
ted with problematic interpersonal relationship patterns. be particularly likely to manifest these responses. Hyper-
For example, CG has been associated with attachment activating strategies in group therapy might be evident
anxiety and deficient interpersonal problem solving through excessive requests for attention and support,
and is more likely to develop among individuals with emotional expression, and talk about the individual
excessive interpersonal dependency (Fraley & Bonanno, who has died. Deactivating strategies might be evident
2004; Maccallum & Bryant, 2013). People who main- through dropping out of the group, withdrawing
tained a supportive, confiding, and dependent relation- emotionally, and withholding personal information
ship with the deceased person are more likely to about the loss. These processes approximate behaviors
develop CG (Bonanno et al., 2008). Interpersonal manifested by group members with anxious and avoi-
changes may therefore be particularly effective for indi- dant attachment styles in other kinds of treatment
viduals with CG when these changes help them effec- groups (Zipora & Rybko, 2004).
tively form and maintain relationships. Given that bereavement groups are often a strong
According to Bowlby’s (1980) attachment based- source of emotional and social support, over time they
model of grieving, attachment insecurity can result when may reduce hyperactivating and deactivating strategies
bereavement leads to loss of an attachment figure. for some individuals. They may also facilitate more
During periods of attachment insecurity, individuals long-term improvements in interpersonal functioning.
may engage in two strategies to bring stability to their There is emerging evidence that attachment patterns
relationship system. Hyperactivating strategies, such as can change during other kinds of group therapy. For
clinging and controlling, attempt to elicit others’ care example, women with binge eating disorder improved
and involvement. Alternatively, deactivating strategies, in their attachment during a 16-week course of group
such as suppressing feelings, denying attachment needs, psychodynamic interpersonal therapy (Keating, Tasca,
and grandiose self enhancement inhibit support seeking & Bissada, 2014). Further, these improvements general-
and increase determination to handle distress alone. ized to relationships outside of the group and were
During normal grieving, oscillation between hyperacti- present 1-year posttreatment. Although this group had
vating and deactivating strategies facilitates attachment an intense relational focus, the authors attributed much
reorganization. Hyperactivating strategies drive people of the change in attachment patterns to the fact that the
to experience the deep pain of loss and reactivate security of the group environment reduced avoidance
168 A. RICE

among group members, which generalized to outside (Yalom & Leszcz, 2005). Meaning-making after loss is a
relationships. Thus, they credited nonspecific group fac- process by which people reconstruct and modify their
tors for many of the changes observed in participants. assumptive models of the world. Ability to find meaning
Similarly, Kinley and Reyno (2013) found improve- in the death can predict the number and severity of grief
ments in secure and fearful attachment following brief outcomes (Coleman & Neimeyer, 2010; Gillies &
group treatment. The treatment was highly structured Neimeyer, 2006). Meaning-making is a particularly
and included elements such as practice working through important process for individuals with CG, which often
painful emotions, increasing self-awareness, improving follows unexpected and=or violent losses that may be
interpersonal relationships, developing coping skills, difficult for people to understand and incorporate into
and challenging dysfunctional thinking. Given the struc- their assumptive models of the world (Neimeyer,
tured nature of the group treatment, it is possible that Baldwin, & Gillies, 2006; Stroebe et al., 2005).
specific treatment factors were responsible for the People often seek to find meaning in a loss when they
changes. However, the authors credited nonspecific pro- experience significant discomfort in processing it
cesses with facilitating change, noting that safe, (Currier, Holland, Coleman, & Neimeyer, 2007; Gillies
empathic group environments can build a sense of safety & Neimeyer, 2006; Neimeyer, 2001). They retain new
and trust among group members and encourage them to meanings that reduce the discomfort. Two main types
challenge ineffective and maladaptive relationship stra- of meaning making in bereavement are benefit-finding,
tegies and beliefs. determining positive aspects of a loss (Neimeyer, 2006)
A study by Ogrodniczuk, Piper, McCallum, Joyce, and sense-making, reconciling existing meaning with
and Rosie (2002) provides evidence that bereavement painful thoughts or emotions related to the loss
groups also provide opportunities for group members (Neimeyer, 2006).
with CG to engage in interpersonal learning. They A number of therapeutic processes relating to
found evidence that interpersonal learning in different meaning-making are effective interventions for CG,
group treatment formats can be associated with including directed writing in which participants focus
improvements in grief outcomes. They found that on sense-making or benefit finding (Lichtenthal &
high-QOR group members improved following Cruess, 2010), revisiting the circumstances around the
interpretative group therapy, whereas low-QOR group death and retelling the story to an individual therapist
members improved more following supportive group (Shear, Frank, Houck, & Reynolds, 2005). Common
therapy. They hypothesized that high-QOR individuals to these studies is the experience and reorganization of
improve more in interpretive groups as they have some some of the cognitions and emotions surrounding the
existing interpersonal skill and support and may there- loss. Similarly, constructing a cognitive narrative in an
fore benefit more from deeper self-analysis. individual format reduced depressive, traumatic, and
Interpersonal learning within the group can also con- CG symptoms (Barbosa, Sá, & Carlos Rocha, 2014).
tribute to changes in group members’ interpersonal rela- Facilitating participants’ ability to explore the events
tionships with important others outside of the group. surrounding grief and evaluate their meaning helped.
Changes in relationships that occurred during group The previous studies looked at the effectiveness of
therapy are still maintained 1 year later, suggesting that experiencing and meaning-making strategies in individ-
these changes may reflect long-term interpersonal learn- ual therapy, but how does meaning-making occur in
ing (Maxwell, Tasca, Ritchie, Balfour, & Bissada, 2013). group therapy? In bereavement groups, participants
Therefore, it seems possible that bereavement groups not only have a safe space to reflect on and discuss exis-
could facilitate long-term changes in attachment and tential concerns and the meaning of the death in their
interpersonal patterns. Thus, although it is unclear if lives, but they can also hear the perspectives of others
nonspecific group factors are sufficient to produce in similar situations and use those perspectives to chal-
changes in attachment and interpersonal functioning, lenge and change the meaning they have made. For
the evidence certainly suggests that they can help facili- example, a qualitative study of the group process in a
tate these changes. therapy group for bereaved parents cited the importance
of parents expressing their narratives and the meaning
drawn from them, stating that the group provided the
Meaning-Making
parents a venue to give their unique interpretation of
In addition to the relational aspects of the loss, many an event (Umphrey & Cacciatore, 2011). Also cocon-
researchers consider the process of making-meaning to structing knowledge in groups and sharing storytelling
be a vital part of the bereavement process (Neimeyer, helped the participants learn new ways of talking about
2001; Stroebe & Schut, 2010). Processing the important the death, handling emotions, and coping with their new
existential questions of life, such as the meaning of loss, reality. Of particular relevance to meaning-making, par-
is an important treatment factor in group psychotherapy ents assessed the degree to which they could relate to
 COMMON THERAPEUTIC FACTORS IN BEREAVEMENT GROUPS 169

other parents’ conceptualizations of their situation and for spouses involved in end-of-life cancer care, due to
whether they could assimilate it into their own story. poor explanation of treatment processes. This criticism
Group members in this study were credited with shaping applies to individual treatment studies as well but may
each other’s perceptions of their losses. However, the be particularly relevant to group studies given that a lar-
authors provided no specific examples of meaning inte- ger proportion of group interactions likely fall outside
gration, limiting conclusions that can be drawn about treatment guidelines.
how participants constructed meanings within the Neglecting nonspecific treatment factors in particular
group. is not unique to the bereavement literature. For
One prediction from Neimeyer et al.’s (2006) model of example, in a qualitative study examining a structured
group meaning formation is that group members experi- group cognitive behavioral treatment for hoarding
ence each others’ discomfort and attempt to provide behaviors, there were rich instances of group members
meanings to alleviate that discomfort. This process may demonstrating universality, cohesion, social support,
help in the sense that the group generates many rich and altruism (Schmalisch, Bratiotis, & Muroff, 2010).
meanings. However, in some situations it may prove prob- Greater accounting of the nonspecific processes in con-
lematic if the group-members provide meanings at the trol and treatment groups would advance understanding
expense of other processes, such as allowing the others of what actually works with whom.
to fully experience emotions related to the loss. Similarly, Researchers could determine the effects of nonspecific
meaning-making might be detrimental if group norms processes on bereavement group outcomes for grief and
reduce the extent to which individuals feel comfortable associated issues such as depression, loneliness, and
expressing or integrating new meanings. Unfortunately other measures of general well-being. These efforts
it is difficult to predict how these processes work within may be challenging because of the difficulty in defining
a bereavement group, as few researchers have examined and measuring these processes, but there are an increas-
the processes by which meanings related to loss are ing number of examples of how this might be achieved
constructed, co-constructed, or adapted within a in the literature on group processes. For example,
bereavement group. Gallagher et al. (2013) defined interpersonal learning as
the extent to which a group member’s level of cohesion
to the group increased over the life of the group and
FUTURE RESEARCH assessed how this related to group outcomes.
Researchers could also examine questions related to
There remain substantial gaps in the literature regarding the nonspecific group processes explored in this article.
these factors. In bereavement groups, researchers could For example, researchers could determine whether
examine how processes operate within treatment effec- group-provided support has more influence on grief
tiveness studies, the importance and interaction of and associated outcomes than in individual therapy, as
specific therapeutic factors, and questions about how suggested by Ogrodniczuk et al. (2009). Given the
therapeutic factors in general relate to processes and evidence that group cohesion moderates a number of
outcomes. treatment outcomes and can influence processes such
A significant problem with the bereavement literature as interpersonal learning, it would be helpful to under-
at present is that there is limited accounting of the treat- stand more about the factors that enhance or disrupt
ment processes in groups. Many studies described cohesion in bereavement groups. It might also be impor-
groups in generic terms such as ‘‘support’’ group, or tant to determine the specific effects of support in
detail specific therapeutic ingredients with little mention bereavement groups. For example there may be signifi-
of the nonspecific elements that might influence the cant overlap between social support, interpersonal
course of treatment. Describing treatment processes learning, and meaning-making. Perhaps, for example,
may be particularly important given the potential over- researchers could determine whether sharing and sup-
lap between specific and non-specific treatment factors. port processes predate interpersonal learning inside
The meaning-making and sharing of emotions sur- and outside the group. They could also look at other
rounding the loss, which occurs spontaneously in routes by which social support in bereavement groups
bereavement support groups, might be difficult to dis- could help, such as by impacting group members’ sense
tinguish from emotional and cognitive processing of of their ability to cope with the loss.
the loss in a cognitive-behaviorally based group with Researchers could also examine how attachment
imaginal exposure. Understanding and describing the models of bereavement translate to group treatment.
group processes would be necessary to determining the For example, how well do group attachment patterns
processes affecting each case. Gauthier and Gagliese relate to the group member’s attachment to the bereaved?
(2012) reported difficulties in reaching conclusions How are attachments formed to the group and what
about the effectiveness of bereavement interventions factors mediate this process? Are hyperactivating and
170 A. RICE

disactivating processes manifested in groups, and how 2013). Group support might be a particularly important
do they change during the life of the group? Previous component of treatment for these clients if it can address
research showing changes in attachment with group these concerns.
treatment has not looked at whether these changes can Individual differences in how group members respond
occur in individuals with CG. If such changes occur, to different therapeutic factors could also be explored.
researchers might also determine the effect of these For example, group members with CG who are experi-
changes on grief or other outcomes. Further, it is unclear encing more interpersonal symptoms, such as a strong
if group members need to have insight into their attach- yearning for the person who died, may respond better
ment to the bereaved or interpersonal patterns to achieve to supportive group processes, whereas individuals who
interpersonal learning and this could also be investigated are experiencing more traumatic symptoms such as
(Marmarosh, 2013). intrusive memories may respond better to imaginal
Given the limited research on meaning-making in exposure (see Shear et al., 2005). Further processes in
bereavement groups, studies could also examine the the group may be affected by individual differences in
way group dynamics affect meaning-making. For the motivations of group members. For example group
example, researchers could determine the kinds of mean- cohesion might be weakened if competition for group
ings that group members share, and whether group resources exists between members who are motivated
members freely express new meanings as they become by benefit-finding strategies, as opposed to members
apparent, or if group-generated meanings tend to who are motivated by sense-making strategies, and mem-
emerge with certain individual ideas being favored and bers who are not motivated to find meaning in the loss.
others suppressed.
Another area for exploration could be the extent to
which different processes affect each other. For CONCLUSION
example, where universality is high, group-members
may share more of their thoughts and emotions sur- Given the popularity of bereavement groups, greater
rounding the loss, as in the case of bereaved parents evidence regarding the presence and interactions of non-
who prefer to talk openly with other bereaved parents specific factors that influence group treatment would
who they perceive as more understanding than others greatly help practitioners refine their groups and ensure
who have not experienced this kind of loss (Riches & positive outcomes for those who attend. Presently the
Dawson, 1996). Open sharing might increase group literature suggests that therapeutic factors related to shar-
effectiveness for individuals with CG who have lower ing and support, interpersonal learning, and meaning-
QOR or attachment anxiety, and who are more likely making all have some potential to affect grief outcomes
to benefit from a supportive than structured group and well-being for those with and without symptoms of
(Tasca et al., 2006; Piper, McCallum, Joyce, Rosie, & CG. Some processes may also affect outcomes indirectly
Ogrodniczuk, 2001). By examining these nonspecific by influencing group member behaviors such as treat-
processes and looking at how they interact and effect ment engagement, which can be low among individuals
outcomes, researchers can learn much more about the with CG (Johnsen, Dryegrov, & Dryegrov, 2012).
functioning of bereavement groups, which could conse- However, more research is needed before definite conclu-
quently improve how group leaders understand and sions can be drawn about how these processes work
manage these processes. within the context of a bereavement group. Many studies
In addition, researchers might examine factors that have evaluated specific interventions, but not enough
moderate the effect of bereavement group processes. work has been done to examine the group processes that
For example, researchers might examine whether type can influence the outcomes of these interventions. Ques-
of loss, such as suicide versus accident, influences the tions regarding what works for whom and how are
effectiveness of different therapeutic factors. Given the especially important given the variety of bereavement
complex thoughts and feelings experienced by suicide experiences among those who participate in bereavement
survivors, groups that emphasize universality and groups, and researchers should ensure that group pro-
meaning-making might be more effective for them than cesses are fully understood before drawing premature
groups that emphasize interpersonal learning (Supiano, conclusions about treatment effectiveness.
2012). Some processes may also have more impact on
group outcomes among individuals who have suffered
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