Getting help, and what the evidence says works

After · 9 min read

The evidence points to a tiered answer rather than a single one. For most bereaved people, formal counseling has not been shown to improve outcomes, and adaptation happens over a period the National Cancer Institute describes as roughly six months to two years. For people at higher risk, targeted support helps. For people with prolonged grief disorder, grief specific psychotherapy works well: trials of grief focused interventions combining cognitive behavioral techniques with exposure and cognitive restructuring have produced response rates reported between 51 and 83 percent. The Columbia Center for Prolonged Grief reports that 70 percent of participants receiving its Prolonged Grief Treatment were much improved. What matters most is matching the level of help to the level of need.

Why it exists

The finding that routine grief counseling does not help everyone is counterintuitive and is often misreported as meaning that grief support does not work. That is not what it says. It says that offering therapy indiscriminately to all bereaved people has not been shown to improve outcomes over what happens anyway, because most people adapt with the support of the people around them.

The corollary is the useful part. Where resources are finite, they are better directed at the minority who are not adapting. The National Cancer Institute's summary describes exactly this tiered approach: universal information for everyone, selective intervention for those at higher risk, and formal treatment reserved for those meeting criteria for complicated or prolonged grief.

Risk is partly predictable. The same summary lists factors associated with worse outcomes, including a lack of social support, a history of depression, lower income, insecure attachment, and deaths that were unexpected or traumatic. Knowing you carry several of these is a reason to seek support early rather than to wait and see.

How it actually works

Start with what is free and low intensity. Peer support groups, hospice bereavement programs, and community and faith based support all sit at this level. Hospices generally provide bereavement support to families for a period after a death as part of the service, and it is frequently unused because nobody mentions it a second time. Ask the hospice directly what it offers and for how long.

Move up a level if the risk factors apply or if functioning is not returning. This is where a clinician with specific grief experience is worth finding. A general therapist without grief training will often default to treating depression, and the National Cancer Institute's summary notes that grief and depression respond differently.

For prolonged grief disorder, use the treatments developed for it. Prolonged Grief Treatment, developed at Columbia, is described by the center as the most extensively tested method available, with 70 percent of participants much improved. Grief focused cognitive behavioral approaches that include exposure to the reality of the death and restructuring of unhelpful beliefs have shown response rates between 51 and 83 percent across randomized trials.

On medication, the position is specific. The American Psychiatric Association notes that no medication currently targets grief symptoms as such. Where depression is present alongside grief, the National Cancer Institute's summary reports that combining an antidepressant with grief directed psychotherapy produced better outcomes than either alone. Medication is therefore a reasonable adjunct where depression coexists, and not a substitute for grief specific work.

Where you stand

You are entitled to ask a clinician about their grief experience before booking, and to ask what approach they use. A clinician who cannot name a grief specific approach may still be helpful, but you should know that going in.

You are entitled to hospice bereavement support if the person died on hospice, generally for a defined period afterward and generally at no cost to you, whether or not you were the enrolled patient's primary caregiver. This is one of the most consistently underused entitlements in this discipline.

You are entitled to mental health coverage under your insurance on the same terms as physical health coverage, under federal parity rules, though the practical details of networks, prior authorization and out of network reimbursement vary by plan and by state. If a claim is denied, ask for the denial in writing and ask what the appeal route is.

You are entitled to stop. Therapy that is not helping after a reasonable trial is information, not a verdict on you. Changing clinician is ordinary and does not require justifying yourself to the first one.

What to do

The mistakes that cost people

Reading the evidence on routine grief counseling as meaning help does not work. It means untargeted help does not reliably beat what happens anyway. Targeted help works well.
Accepting an antidepressant as the whole treatment. No medication currently targets grief itself, and the evidence favors combining medication with grief directed therapy where depression is also present.
Missing the hospice bereavement window. It is usually time limited, it is usually free, and it usually goes unclaimed.
Staying with a clinician who is not helping because changing feels like failure. It is information about fit, and switching is ordinary.

Words you will meet

prolonged grief treatment: The grief specific psychotherapy developed at Columbia University, the most extensively tested treatment for prolonged grief disorder.
cognitive behavioral therapy: A structured talking therapy that works on the relationship between thoughts, feelings and behavior, and which underlies most grief specific treatments.
exposure: A therapy component involving deliberate, supported contact with avoided reminders of the death, used within grief focused treatments.
response rate: The proportion of people in a trial who improved meaningfully on the measure being used, which is how treatment effectiveness is usually reported.
bereavement support: Non-clinical support after a death, including peer groups and hospice programs, which sits below formal therapy in intensity.
parity: The federal requirement that insurance plans cover mental health conditions on terms comparable to physical health conditions.

What this does not cover

This module does not cover treatment for children and adolescents, treatment for post traumatic stress disorder following a traumatic death, or the specific supports available after a death by suicide or overdose, each of which needs its own guidance and its own clinicians.

Go deeper

These are the primary sources. When in doubt, trust them over anyone, including us.

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